Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

  • Knowledge Base

Methodology

  • What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

Here's why students love Scribbr's proofreading services

Discover proofreading & editing

Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

  • Provide new or unexpected insights into the subject
  • Challenge or complicate existing assumptions and theories
  • Propose practical courses of action to resolve a problem
  • Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Normal distribution
  • Degrees of freedom
  • Null hypothesis
  • Discourse analysis
  • Control groups
  • Mixed methods research
  • Non-probability sampling
  • Quantitative research
  • Ecological validity

Research bias

  • Rosenthal effect
  • Implicit bias
  • Cognitive bias
  • Selection bias
  • Negativity bias
  • Status quo bias

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

McCombes, S. (2023, November 20). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved February 16, 2024, from https://www.scribbr.com/methodology/case-study/

Is this article helpful?

Shona McCombes

Shona McCombes

Other students also liked, primary vs. secondary sources | difference & examples, what is a theoretical framework | guide to organizing, what is action research | definition & examples, what is your plagiarism score.

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

  • Knowledge Base
  • Methodology
  • Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

Published on 5 May 2022 by Shona McCombes . Revised on 30 January 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating, and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyse the case.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

Prevent plagiarism, run a free check.

Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

  • Provide new or unexpected insights into the subject
  • Challenge or complicate existing assumptions and theories
  • Propose practical courses of action to resolve a problem
  • Open up new directions for future research

Unlike quantitative or experimental research, a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

If you find yourself aiming to simultaneously investigate and solve an issue, consider conducting action research . As its name suggests, action research conducts research and takes action at the same time, and is highly iterative and flexible. 

However, you can also choose a more common or representative case to exemplify a particular category, experience, or phenomenon.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews, observations, and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data .

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis, with separate sections or chapters for the methods , results , and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyse its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 15 February 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

Is this article helpful?

Shona McCombes

Shona McCombes

Other students also liked, correlational research | guide, design & examples, a quick guide to experimental design | 5 steps & examples, descriptive research design | definition, methods & examples.

MIT Press

On the site

Belfer center studies in international security.

  • political science

Case Studies and Theory Development in the Social Sciences

Case Studies and Theory Development in the Social Sciences

by Alexander L. George and Andrew Bennett

  • $35.00 Paperback
  • Rent eTextbook

352 pp. , 6 x 9 in ,

  • 9780262572224
  • Published: April 15, 2005
  • Publisher: The MIT Press
  • 9780262072571
  • Published: April 22, 2005
  • 9780262262897
  • Amazon.co.uk
  • Bookshop.org
  • Waterstones

Other Retailers:

  • MIT Press Bookstore
  • Penguin Random House
  • Barnes and Noble
  • Books a Million
  • Request exam/desk copy
  • Request permissions
  • Description

The use of case studies to build and test theories in political science and the other social sciences has increased in recent years. Many scholars have argued that the social sciences rely too heavily on quantitative research and formal models and have attempted to develop and refine rigorous methods for using case studies. This text presents a comprehensive analysis of research methods using case studies and examines the place of case studies in social science methodology. It argues that case studies, statistical methods, and formal models are complementary rather than competitive.

The book explains how to design case study research that will produce results useful to policymakers and emphasizes the importance of developing policy-relevant theories. It offers three major contributions to case study methodology: an emphasis on the importance of within-case analysis, a detailed discussion of process tracing, and development of the concept of typological theories. Case Studies and Theory Development in the Social Sciences will be particularly useful to graduate students and scholars in social science methodology and the philosophy of science, as well as to those designing new research projects, and will contribute greatly to the broader debate about scientific methods.

Alexander L. George was Graham H. Stuart Professor of Political Science Emeritus at Stanford University and the author or coauthor of many books, most recently Presidential Personality and Performance (1998).

Andrew Bennett is Associate Professor of Government at Georgetown University and the author of Condemned to Repetition? The Rise, Fall, and Reprise of Soviet-Russian Military Interventionism, 1973-1996 (MIT Press, 1999).

In this book, George and Bennett explain how research methods such as process tracing and comparative case studies are designed, carried out, and used as the basis for theory development in social science. They provide an invaluable research guide for any scholar interested in the case study approach. But the book is much more than an account of how to do case study research. The authors also offer a sophisticated discussion of the philosophy of science that will be useful to anyone interested in the place of case-study methods in broader debates about social science methodology, and they give a discerning analysis of policy-relevant theory that is sure to draw the attention of a research community increasingly concerned about the social and political relevance of modern social science. In scope, clarity, and erudition, this book sets a new standard not only in the analysis of case study methods, but also in the study of social science methods more broadly. David Dessler, Associate Professor of Government, College of William & Mary
This book combines clear and concise instructions on how to do qualitative research with sophisticated but accessible epistemological reasons for that advice. The volume provides step-by-step templates on ways to design research, compare across cases, congruence test and process trace, and use typological theories. This guidance is illustrated with dozens of concrete examples. Almost no other methodology text comes close to matching the authors' top-to-bottom synthesis of philosophy of science and practical advice. Colin Elman, Executive Director, Consortium on Qualitative Research Methods, Assistant Professor of Political Science, Arizona State University
This landmark study offers to scholars of all methodological persuasions a philosophically informed, theoretically nuanced, and methodologically detailed treatment of case study analysis. With this book Alexander George and Andrew Bennett help all of us in improving our research, teaching, and disciplinary debates. Peter J. Katzenstein, Walter S. Carpenter, Jr., Professor of International Studies, Cornell University
Case Studies and Theory Development in the Social Sciences makes an indispensable contribution to the growing literature on qualitative methods in the social sciences. It provides a definitive analysis of case study methods and research designs, anchors those methods in contemporary philosophy of science, and argues that case study, statistical, and formal approaches can and should be mutually reinforcing in the development and testing of social theories. Jack S. Levy, Board of Governors' Professor, Rutgers University
Today, more and more social scientists recognize the importance of cases in social and political research and are looking for new ways to make their research more case oriented. George and Bennett show how in this important new work. The beauty of their approach is their careful integration of theory and method and their conviction that the pursuit of empirical knowledge is profoundly theory dependent. Charles Ragin, Professor of Sociology, University of Arizona
Andrew Bennett and Alexander George have written an immensely helpful practical guide to the case method. It offers sharp insight on scientific inference and very useful how-to guidance on doing case studies. Graduate students in social science: don't leave home without it! Stephen Van Evera, Professor of Political Science, Massachusetts Institute of Technology
The history of social science shows that well-designed case studies can be both a fertile source of new theories and a powerful tool for testing them. Case Studies and Theory Development in the Social Sciences raises our understanding of case study methodology to a new level of rigor and sophistication. George and Bennett provide a careful analysis of the virtues and pitfalls of comparative case study research and offer valuable advice for any scholar engaged in qualitative research. The more widely this book is read, the better future social science will be. Stephen M. Walt, Robert and Renée Belfer Professor of International Affairs, John F. Kennedy School of Government, Harvard University
This is an extraordinarily valuable book—a guide written with the practitioner in mind, very sophisticated in its approach to the subject, but loaded with practical advice. George and Bennett show how systematic, rigorous, and above all meaningful case study work is to be done. This is the sort of book scholars—and not just graduate students—will want to come back to over and over again. Marc Trachtenberg, Professor of Political Science, University of California, Los Angeles

Sample Chapter

Related Books

Breathing

  • Subject List
  • Take a Tour
  • For Authors
  • Subscriber Services
  • Publications
  • African American Studies
  • African Studies
  • American Literature
  • Anthropology
  • Architecture Planning and Preservation
  • Art History
  • Atlantic History
  • Biblical Studies
  • British and Irish Literature
  • Childhood Studies
  • Chinese Studies
  • Cinema and Media Studies
  • Communication
  • Criminology
  • Environmental Science
  • Evolutionary Biology
  • International Law

International Relations

  • Islamic Studies
  • Jewish Studies
  • Latin American Studies
  • Latino Studies
  • Linguistics
  • Literary and Critical Theory
  • Medieval Studies
  • Military History
  • Political Science
  • Public Health
  • Renaissance and Reformation
  • Social Work
  • Urban Studies
  • Victorian Literature
  • Browse All Subjects

How to Subscribe

  • Free Trials

In This Article Expand or collapse the "in this article" section Case Study Methods in International Relations

Introduction, textbooks and monographs.

  • What Is a Case Study?
  • Case Study Design
  • Case Studies and Understanding Concepts
  • Case Studies, Theory Testing, and Theory Generation
  • Case Studies and Causality
  • Case Studies and Process-Tracing
  • Case Studies and Interpretive Research

Related Articles Expand or collapse the "related articles" section about

About related articles close popup.

Lorem Ipsum Sit Dolor Amet

Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Aliquam ligula odio, euismod ut aliquam et, vestibulum nec risus. Nulla viverra, arcu et iaculis consequat, justo diam ornare tellus, semper ultrices tellus nunc eu tellus.

  • Experiments
  • Interviews and Focus Groups
  • The Empirical Testing of Formal Models

Other Subject Areas

Forthcoming articles expand or collapse the "forthcoming articles" section.

  • Crisis Bargaining
  • History of Brazilian Foreign Policy (1808 to 1945)
  • Indian Foreign Policy
  • Find more forthcoming articles...
  • Export Citations
  • Share This Facebook LinkedIn Twitter

Case Study Methods in International Relations by Christopher K. Lamont LAST REVIEWED: 11 July 2019 LAST MODIFIED: 29 November 2017 DOI: 10.1093/obo/9780199743292-0225

Case studies are perhaps the most widely used research design in international relations (IR). Across the discipline’s subfields of security studies, international political economy, foreign policy analysis, and international political theory, case studies have become ubiquitous. As such, it is not surprising that case studies have been the subject of debate as to what constitutes a case study, how to conduct or design case studies, the potential contribution of case studies to general, or case specific, knowledge in the field of IR, and of course, how to evaluate case studies. To be sure, debates on case study research in IR mirror the field’s methodological pluralism and broader debates on methodology. Case studies have been widely used by interpretivist and positivist scholars of IR alike. It is for this reason that literature on case study design contains scholarship that on the one hand aims to emphasize how case study design, and case selection strategies, can help generalize findings beyond specific cases to literature on the other hand that emphasizes the historic, contextual and descriptive richness of case studies. However, it will become apparent in this bibliography that most scholarship that deals explicitly with the case study method has done so from a positivist perspective on the social sciences. Indeed, each methodological standpoint advances distinct claims as to the purpose and contribution of case studies to IR. Therefore, as we will see in the overview of scholarship presented here within this bibliography, early methodological literature on case studies in IR, political science, and comparative politics, attempted to evaluate the utility, or contribution, of case studies along the lines of the extent to which case studies could contribute to causal explanation and generalizability. However, it is also the case that today, as in the past, IR scholarship that utilizes case study design cuts across both methodological traditions as not all scholars of IR deploy case studies for the purpose of explanation. Indeed, although there has been much discussion in the literature on case study design with an aim to maximize causal inference within the positivist tradition, this bibliography will highlight scholarship on case studies that includes both positivist debates on causality, inference, and generalization, and scholarship that embraces case studies as a means of producing deeper context-dependent knowledge on a given topic, notion, or concept. The first sections will present general texts and journals on case study research relevant to IR. The following texts are general textbooks or monographs on case study research design and methods. While there is a growing body of methodological scholarship that focuses on case studies in the social science that makes reference to research in IR, most of the texts below have a broader disciplinary focus. This is because debates over case study methods have tended to center around wider philosophy of social science debates on causal inference and the study of the social world.

In recent years the growing popularity of case studies in international relations (IR) has coincided with a growth in textbooks and monographs that examine case study methods. These range from broad texts on research methods in the social sciences ( Blatter and Haverland 2012 , Burton 2000 ) that sometimes contain collections of essays on case study design and research ( Gomm, et al. 2000 ) or provide examples of case studies drawn from a wide range of cognate disciplines ( Yin 2004 ). For scholars of IR, the most discipline-specific broader text is Case Studies and Theory Development in the Social Sciences ( George and Bennett 2005 ), while Qualitative Methods in International Relations ( Klotz and Prakash 2008 ) also contains contributions that explicitly address case study methods, or methods such as process tracing, that are relevant to case study research. Also of note are texts that provide readers with guidance on how to conduct case studies ( Thomas 2016 , Yin 2014 ). An example of a text that both reflects on case study methods and also provides practical how-to guidance is Case Study Research ( Gerring 2017 ).

Blatter, Joachim, and Markus Haverland. Designing Case Studies: Explanatory Approaches in Small-N Research . New York: Palgrave Macmillan, 2012.

DOI: 10.1057/9781137016669

This text presents an overview of case study methods that makes the case for a pluralist case study epistemology. Blatter and Haverland explore case study design in the context of co-variational analysis, causal process tracing, and congruence analysis.

Burton, Dawn. Research Training for Social Scientists . London: SAGE, 2000.

DOI: 10.4135/9780857028051

This is a broad text on research methods in the social sciences that contains specific chapters relevant to case study research that provide a basic introduction to case study research. See in particular chapter 16, which sets out uses of case studies in social science research.

George, Alexander L., and Andrew Bennett. Case Studies and Theory Development in the Social Sciences . Cambridge, MA: MIT, 2005.

This text provides an in-depth assessment of case study research design for researchers whose focus is on designing case studies for theory testing. While the first part of the book provides an in-depth overview of social science debates on the merits of case studies, the second part provides a guide for researchers to conduct case study research. This text draws upon examples from both international relations and political science research.

Gerring, John. Case Study Research: Principles and Practices . 2d ed. Cambridge, UK: Cambridge University Press, 2017.

This textbook provides an overview of case study research design that primarily addresses strategies for maximizing causal inference in case study research, but also provides an overview of descriptive case studies. This text contains a practical guide to doing case study research and analyzing findings.

Gomm, Roger, Martyn Hammersley, and Peter Foster, eds. Case Study Methods: Key Issues, Key Texts . London: SAGE, 2000.

This is a general collection of essays that addresses core elements of case study design and research. It contains numerous contributions on case studies and generalizability and case studies and theory. The latter includes a contribution by Harry Eckstein on case study research in political science.

Klotz, Audie, and Deepa Prakash, eds. Qualitative Methods in International Relations: A Pluralist Guide . New York: Palgrave MacMillan, 2008.

This volume contains numerous useful contributions relevant to case study methods that range from Klotz’s chapter on case selection to a contribution on process tracing by Jeffrey Checkel.

Thomas, Garry. How to Do Your Case Study . 2d ed. London: SAGE, 2016.

This is an accessible guide for case study research whose primary audience is students. It begins with defining case studies and strategies for case design before presenting a practical guide to carrying out case study research.

Yin, Robert K. The Case Study Anthology . London: SAGE, 2004.

This collection of essays includes examples of case studies drawn from IR, political science, sociology, and other related disciplines.

Yin, Robert K. Case Study Research: Design and Methods . 5th ed. London: SAGE, 2014.

This textbook provides a comprehensive overview of case study research. Starting from providing definitions for case studies, this textbook goes on to provide a practical guide for students to conduct their own case studies.

back to top

Users without a subscription are not able to see the full content on this page. Please subscribe or login .

Oxford Bibliographies Online is available by subscription and perpetual access to institutions. For more information or to contact an Oxford Sales Representative click here .

  • About International Relations »
  • Meet the Editorial Board »
  • Academic Theories of International Relations Since 1945
  • Al-Qaeda in the Islamic Maghreb
  • Arab-Israeli Wars
  • Arab-Israeli Wars, 1967-1973, The
  • Armed Conflicts/Violence against Civilians Data Sets
  • Arms Control
  • Asylum Policies
  • Audience Costs and the Credibility of Commitments
  • Authoritarian Regimes
  • Balance of Power Theory
  • Bargaining Theory of War
  • Brazilian Foreign Policy, The Politics of
  • Canadian Foreign Policy
  • Case Study Methods in International Relations
  • Casualties and Politics
  • Causation in International Relations
  • Central Europe
  • Challenge of Communism, The
  • China and Japan
  • China's Defense Policy
  • China’s Foreign Policy
  • Chinese Approaches to Strategy
  • Cities and International Relations
  • Civil Resistance
  • Civil Society in the European Union
  • Cold War, The
  • Colonialism
  • Comparative Foreign Policy Security Interests
  • Comparative Regionalism
  • Complex Systems Approaches to Global Politics
  • Conflict Behavior and the Prevention of War
  • Conflict Management
  • Conflict Management in the Middle East
  • Constructivism
  • Contemporary Shia–Sunni Sectarian Violence
  • Counterinsurgency
  • Countermeasures in International Law
  • Coups and Mutinies
  • Criminal Law, International
  • Critical Theory of International Relations
  • Cuban Missile Crisis, The
  • Cultural Diplomacy
  • Cyber Security
  • Cyber Warfare
  • Decision-Making, Poliheuristic Theory of
  • Demobilization, Post World War I
  • Democracies and World Order
  • Democracy and Conflict
  • Democracy in World Politics
  • Deterrence Theory
  • Development
  • Digital Diplomacy
  • Diplomacy, Gender and
  • Diplomacy, History of
  • Diplomacy in the ASEAN
  • Diplomacy, Public
  • Disaster Diplomacy
  • Diversionary Theory of War
  • Drone Warfare
  • Eastern Front (World War I)
  • Economic Coercion and Sanctions
  • Economics, International
  • Embedded Liberalism
  • Emerging Powers and BRICS
  • Empirical Testing of Formal Models
  • Energy and International Security
  • Environmental Peacebuilding
  • Epidemic Diseases and their Effects on History
  • Ethics and Morality in International Relations
  • Ethnicity in International Relations
  • European Migration Policy
  • European Security and Defense Policy, The
  • European Union as an International Actor
  • European Union, International Relations of the
  • Face-to-Face Diplomacy
  • Fascism, The Challenge of
  • Feminist Methodologies in International Relations
  • Feminist Security Studies
  • Food Security
  • Forecasting in International Relations
  • Foreign Aid and Assistance
  • Foreign Direct Investment
  • Foreign Policy Decision-Making
  • Foreign Policy of Non-democratic Regimes
  • Foreign Policy of Saudi Arabia
  • Foreign Policy, Theories of
  • French Empire, 20th-Century
  • From Club to Network Diplomacy
  • Future of NATO
  • Game Theory and Interstate Conflict
  • Gender and Terrorism
  • Genocide, Politicide, and Mass Atrocities Against Civilian...
  • Genocides, 20th Century
  • Geopolitics and Geostrategy
  • Germany in World War II
  • Global Citizenship
  • Global Civil Society
  • Global Constitutionalism
  • Global Environmental Politics
  • Global Ethic of Care
  • Global Governance
  • Global Justice, Western Perspectives
  • Globalization
  • Governance of the Arctic
  • Grand Strategy
  • Greater Middle East, The
  • Greek Crisis
  • Hague Conferences (1899, 1907)
  • Hierarchies in International Relations
  • History and International Relations
  • Human Nature in International Relations
  • Human Rights
  • Human Rights and Humanitarian Diplomacy
  • Human Rights, Feminism and
  • Human Rights Law
  • Human Security
  • Hybrid Warfare
  • Ideal Diplomat, The
  • Identity and Foreign Policy
  • Ideology, Values, and Foreign Policy
  • Illicit Trade and Smuggling
  • Imperialism
  • Indian Perspectives on International Relations, War, and C...
  • Indigenous Rights
  • Industrialization
  • Intelligence
  • Intelligence Oversight
  • Internal Displacement
  • International Conflict Settlements, The Durability of
  • International Criminal Court, The
  • International Economic Organizations (IMF and World Bank)
  • International Health Governance
  • International Justice, Theories of
  • International Law, Feminist Perspectives on
  • International Monetary Relations, History of
  • International Negotiation and Conflict Resolution
  • International Nongovernmental Organizations
  • International Norms for Cultural Preservation and Cooperat...
  • International Organizations
  • International Relations, Aesthetic Turn in
  • International Relations as a Social Science
  • International Relations, Practice Turn in
  • International Relations, Research Ethics in
  • International Relations Theory
  • International Security
  • International Society
  • International Society, Theorizing
  • International Support For Nonstate Armed Groups
  • Internet Law
  • Interstate Cooperation Theory and International Institutio...
  • Intervention and Use of Force
  • Iran, Politics and Foreign Policy
  • Iraq: Past and Present
  • Japanese Foreign Policy
  • Just War Theory
  • Kurdistan and Kurdish Politics
  • Law of the Sea
  • Laws of War
  • Leadership in International Affairs
  • Leadership Personality Characteristics and Foreign Policy
  • League of Nations
  • Lean Forward and Pull Back Options for US Grand Strategy
  • Mediation and Civil Wars
  • Mediation in International Conflicts
  • Mediation via International Organizations
  • Memory and World Politics
  • Mercantilism
  • Middle East, The Contemporary
  • Middle Powers and Regional Powers
  • Military Science
  • Minorities in the Middle East
  • Minority Rights
  • Morality in Foreign Policy
  • Multilateralism (1992–), Return to
  • National Liberation, International Law and Wars of
  • National Security Act of 1947, The
  • Nation-Building
  • Nations and Nationalism
  • NATO, Europe, and Russia: Security Issues and the Border R...
  • Natural Resources, Energy Politics, and Environmental Cons...
  • New Multilateralism in the Early 21st Century
  • Nonproliferation and Counterproliferation
  • Nonviolent Resistance Datasets
  • Normative Aspects of International Peacekeeping
  • Normative Power Beyond the Eurocentric Frame
  • Nuclear Proliferation
  • Peace Education in Post-Conflict Zones
  • Peace of Utrecht
  • Peacebuilding, Post-Conflict
  • Peacekeeping
  • Political Demography
  • Political Economy of National Security
  • Political Extremism in Sub-Saharan Africa
  • Political Learning and Socialization
  • Political Psychology
  • Politics and Islam in Turkey
  • Politics and Nationalism in Cyprus
  • Politics of Extraction: Theories and New Concepts for Crit...
  • Politics of Resilience
  • Popuism and Global Politics
  • Popular Culture and International Relations
  • Post-Civil War State
  • Post-Conflict and Transitional Justice
  • Post-Conflict Reconciliation in the Middle East and North ...
  • Power Transition Theory
  • Preventive War and Preemption
  • Prisoners, Treatment of
  • Private Military and Security Companies (PMSCs)
  • Process Tracing Methods
  • Pro-Government Militias
  • Proliferation
  • Prospect Theory in International Relations
  • Psychoanalysis in Global Politics and International Relati...
  • Psychology and Foreign Policy
  • Public Opinion and Foreign Policy
  • Public Opinion and the European Union
  • Quantum Social Science
  • Race and International Relations
  • Rebel Governance
  • Reconciliation
  • Reflexivity and International Relations
  • Religion and International Relations
  • Religiously Motivated Violence
  • Reputation in International Relations
  • Responsibility to Protect
  • Rising Powers in World Politics
  • Role Theory in International Relations
  • Russian Foreign Policy
  • Russian Revolutions and Civil War, 1917–1921
  • Sanctions in International Law
  • Science Diplomacy
  • Second Sino-Japanese War (1937-1945), The
  • Secrecy and Diplomacy
  • Securitization
  • Self-Determination
  • Shining Path
  • Sinophone and Japanese International Relations Theory
  • Small State Diplomacy
  • Social Scientific Theories of Imperialism
  • Sovereignty
  • Soviet Union in World War II
  • Space Strategy, Policy, and Power
  • Spatial Dependencies and International Mediation
  • State Theory in International Relations
  • Status in International Relations
  • Strategic Air Power
  • Strategic and Net Assessments
  • Sub-Saharan Africa, Conflict Formations in
  • Sustainable Development
  • Systems Theory
  • Teaching International Relations
  • Territorial Disputes
  • Terrorism and Poverty
  • Terrorism, Geography of
  • Terrorist Financing
  • Terrorist Group Strategies
  • The Changing Nature of Diplomacy
  • The Politics and Diplomacy of Neutrality
  • The Politics and Diplomacy of the First World War
  • The Queer in/of International Relations
  • the Twenty-First Century, Alliance Commitments in
  • The Vienna Conventions on Diplomatic and Consular Relation...
  • Theories of International Relations, Feminist
  • Theory, Chinese International Relations
  • Time Series Approaches to International Affairs
  • Transnational Actors
  • Transnational Law
  • Transnational Social Movements
  • Tribunals, War Crimes and
  • Trust and International Relations
  • UN Security Council
  • United Nations, The
  • United States and Asia, The
  • Uppsala Conflict Data Program
  • US and Africa
  • US–UK Special Relationship
  • Voluntary International Migration
  • War of the Spanish Succession (1701-1714)
  • Weapons of Mass Destruction
  • Western Balkans
  • Western Front (World War I)
  • Westphalia, Peace of (1648)
  • Women and Peacemaking Peacekeeping
  • World Economy 1919-1939
  • World Polity School
  • World War II Diplomacy and Political Relations
  • World-System Theory
  • Privacy Policy
  • Cookie Policy
  • Legal Notice
  • Accessibility

Powered by:

  • [66.249.64.20|81.177.182.174]
  • 81.177.182.174

Academic Success Center

Qualitative & Quantitative Research Support

  • NVivo Group and Study Sessions
  • SPSS This link opens in a new window
  • Statistical Analysis Group sessions
  • Using Qualtrics
  • Dissertation and Data Analysis Group Sessions
  • Boot Camp This link opens in a new window
  • Research Process Flow Chart
  • Research Alignment This link opens in a new window
  • Step 1: Seek Out Evidence
  • Step 2: Explain
  • Step 3: The Big Picture
  • Step 4: Own It
  • Step 5: Illustrate
  • Annotated Bibliography
  • Literature Review This link opens in a new window
  • Systematic Reviews & Meta-Analyses
  • How to Synthesize and Analyze
  • Synthesis and Analysis Practice
  • Synthesis and Analysis Group Sessions
  • Problem Statement
  • Purpose Statement
  • Quantitative Research Questions
  • Qualitative Research Questions
  • Trustworthiness of Qualitative Data
  • Analysis and Coding Example- Qualitative Data
  • Thematic Data Analysis in Qualitative Design
  • Dissertation to Journal Article This link opens in a new window
  • International Journal of Online Graduate Education (IJOGE) This link opens in a new window
  • Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

Writing a Case Study

Hands holding a world globe

What is a case study?

A Map of the world with hands holding a pen.

A Case study is: 

  • An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
  • Used to examine an identifiable problem confirmed through research.
  • Used to investigate an individual, group of people, organization, or event.
  • Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Man and woman looking at a laptop

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

Boys looking through a camera

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

Triangulation image with examples

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

Man holding his hand out to show five fingers.

Was this resource helpful?

  • << Previous: Thematic Data Analysis in Qualitative Design
  • Next: Journal Article Reporting Standards (JARS) >>
  • Last Updated: Feb 9, 2024 11:17 AM
  • URL: https://resources.nu.edu/researchtools

NCU Library Home

  • Privacy Policy
  • SignUp/Login

Research Method

Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

Case Study Research

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

  • Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
  • Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
  • Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
  • Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
  • Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
  • Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
  • Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

  • The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
  • The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
  • The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
  • The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
  • The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

  • Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
  • Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
  • Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
  • Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

  • In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
  • Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
  • Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
  • Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
  • Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
  • Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

  • Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
  • Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
  • Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
  • Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
  • Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
  • Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

' src=

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Qualitative Research

Qualitative Research – Methods, Analysis Types...

Descriptive Research Design

Descriptive Research Design – Types, Methods and...

Qualitative Research Methods

Qualitative Research Methods

Basic Research

Basic Research – Types, Methods and Examples

Exploratory Research

Exploratory Research – Types, Methods and...

One-to-One Interview in Research

One-to-One Interview – Methods and Guide

Adapting and blending grounded theory with case study: a practical guide

  • Published: 08 December 2023

Cite this article

  • Charles Dahwa   ORCID: orcid.org/0000-0002-7705-4627 1  

128 Accesses

6 Altmetric

Explore all metrics

This article tackles how to adapt grounded theory by blending it with case study techniques. Grounded theory is commended for enabling qualitative researchers to avoid priori assumptions and intensely explore social phenomena leading to enhanced theorization and deepened contextualized understanding. However, it is criticized for generating enormous data that is difficult to manage, contentious treatment of literature review and category saturation. Further, while the proliferation of several versions of grounded theory brings new insights and some clarity, inevitably some bits of confusion also creep in, given the dearth of standard protocols applying across such versions. Consequently, the combined effect of all these challenges is that grounded theory is predominantly perceived as very daunting, costly and time consuming. This perception is discouraging many qualitative researchers from using grounded theory; yet using it immensely benefits qualitative research. To gradually impart grounded theory skills and to encourage its usage a key solution is to avoid a full-scale grounded theory but instead use its adapted version, which exploits case study techniques. How to do this is the research question for this article. Through a reflective account of my PhD research methodology the article generates new insights by providing an original and novel empirical account about how to adapt grounded theory blending it with case study techniques. Secondly, the article offers a Versatile Interview Cases Research Framework (VICaRF) that equips qualitative researchers with clear research questions and steps they can take to effectively adapt grounded theory by blending it with case study techniques.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

case study in theory

Allwood, C.M.: The distinction between qualitative and quantitative research methods is problematic. Qual. Quant. 46 (5), 1417–1429 (2012)

Article   Google Scholar  

Andrade, A.D.: Interpretive research aiming at theory building: adopting and adapting the case study design. Qual. Rep. 14 (1), 42–60 (2009)

Google Scholar  

Bruscaglioni, L.: Theorizing in grounded theory and creative abduction. Qual. Quant. 50 (5), 2009–2024 (2016)

Burrell, G., Morgan, G.: Sociological Paradigms and Organizational Analysis: Elements of the Sociology of Corporate Life. Heinemann, London (1979)

Chalmers, A.F.: What is This Thing Called Science? Open University Press, Maidenhead (1999)

Chamberlain, G.P.: Researching strategy formation process: an abductive methodology. Qual. Quant. 40 , 289–301 (2006)

Charmaz, K.: Constructing Grounded Theory: A Practical Guide Through Qualitative Research. Sage Publications Ltd, London (2006)

Charmaz, K.: Constructing Grounded Theory. SAGE, London (2014)

Cooke, F.L.: Concepts, contexts, and mindsets: putting human resource management research in perspectives. Hum. Resour. Manag. 28 (1), 1–13 (2017)

Cope, J.: Toward a dynamic learning perspective of entrepreneurship. Entrep. Theory Pract. 29 (4), 373–397 (2005)

Corbin, J., Strauss, A.: Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 4th edn. Sage, Thousand Oaks, CA (2015)

Creswell, J.W.: Qualitative Inquiry & research design: Choosing among five approaches, 3rd edn. Sage Publications Ltd., London (2013)

Dey, I.: Grounding Grounded Theory: Guidelines for Qualitative Inquiry. Academic, San Diego, CA (1999)

Diefenbach, T.: Are case studies more than sophisticated storytelling?: Methodological problems of qualitative empirical research mainly based on semi-structured interviews. Qual. Quant. 43 (6), 875–894 (2009)

Dunne, C.: The place of the literature review in grounded theory research. Int. J. Soc. Res. Methodol. 14 (2), 111–124 (2011)

Fairhurst, G.T., Putnam, L.L.: An integrative methodology for organizational oppositions: aligning grounded theory and discourse analysis. Organ. Res. Methods 22 (4), 917–940 (2019)

Francis, J.J., Johnston, M., Robertson, C., Glidewell, L., Entwistle, V., Eccles, M.P., Grimshaw, J.M.: What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol. Health 25 (10), 1229–1245 (2010)

Glaser, B.: Doing Grounded Theory: Issues and Discussions. Sociology Press, Mill Valley, CA (1998)

Glaser, B.G., Strauss, A.L.: The discovery of grounded theory: strategies for qualitative research. Aldine de Gruyter, Chicago, IL (1967)

Gordon, J.: The voice of the social worker: a narrative literature review. Br. J. Soc. Work. 48 (5), 1333–1350 (2018)

Hlady-Rispal, M., Jouison-Laffitte, E.: Qualitative research methods and epistemological frameworks: a review of publication trends in entrepreneurship. J. Small Bus. Manag. 52 (4), 594–614 (2014)

Iman, M.T., Boostani, D.: A qualitative investigation of the intersection of leisure and identity among high school students: application of grounded theory. Qual. Quant. 46 (2), 483–499 (2012)

Katz, J.A., Aldrich, H.E., Welbourne, T.M., Williams, P.M.: Guest editor’s comments special issue on human resource management and the SME: toward a new synthesis. Entrep. Theory Pract. 25 (1), 7–10 (2000)

Kibuku, R.N., Ochieng, D.O., Wausi, A.N.: Developing an e-learning theory for interaction and collaboration using grounded theory: a methodological approach. Qual. Rep. 26 (9), 0_1-2854 (2021)

Lai, Y., Saridakis, G., Johnstone, S.: Human resource practices, employee attitudes and small firm performance. Int. Small Bus. J. 35 (4), 470–494 (2017)

Lauckner, H., Paterson, M., Krupa, T.: Using constructivist case study methodology to understand community development processes: proposed methodological questions to guide the research process. Qual. Rep. 17 (13), 1–22 (2012)

Levers, M.J.D.: Philosophical paradigms, grounded theory, and perspectives on emergence, pp. 1–6. Sage Open, London (2013)

Marlow, S.: Human resource management in smaller firms: a contradiction in terms? Hum. Resour. Manag. Rev. 16 (4), 467–477 (2006)

Marlow, S., Taylor, S., Thompson, A.: Informality and formality in medium sized companies: contestation and synchronization. Br. J. Manag. 21 (4), 954–966 (2010)

Mason, M.: Sample size and saturation in PhD studies using qualitative interviews. Qual. Soc. Res. (2010). https://doi.org/10.17169/fqs-11.3.1428

Mauceri, S.: Mixed strategies for improving data quality: the contribution of qualitative procedures to survey research. Qual. Quant. 48 , 2773–2790 (2014)

Mullen, M., Budeva, D.G., Doney, P.M.: Research methods in the leading small business entrepreneurship journals: a critical review with recommendations for future research. J. Small Bus. Manage. 47 (3), 287–307 (2009)

Niaz, M.: Can findings of qualitative research in education be generalized? Qual. Quant. 41 (3), 429–445 (2007)

Nolan, C.T., Garavan, T.N.: Human resource development in SMEs: a systematic review of the literature. Int. J. Manag. Rev. 18 (1), 85–107 (2016)

Onwuegbuzie, A.J., Leech, N.L.: A call for qualitative power analyses. Qual. Quant. 41 (1), 105–121 (2007)

Pentland, B.T.: Building process theory with narrative: from description to explanation. Acad. Manag. Rev. 24 (4), 711–724 (1999)

Popper, K.: The Logic of Scientific Discovery. Hutchinson, Tuebingen (1959)

Ramalho, R., Adams, P., Huggard, P., Hoare, K.: Literature review and constructivist grounded theory methodology. Qual. Soc. Res. J. 16 (3), 1–13 (2015)

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., Jinks, C.: Saturation in qualitative research: exploring its conceptualization and operationalization. Qual. Quant. 52 , 1893–1907 (2018)

Sharma, G., Kulshreshtha, K., Bajpai, N.: Getting over the issue of theoretical stagnation: an exploration and metamorphosis of grounded theory approach. Qual. Quant. 56 (2), 857–884 (2022)

Stake, R.E.: The Art of Case Study Research. Sage, Thousand Oaks, CA (1995)

Strauss, A.L., Corbin, J.: The Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage, Newbury Park, CA (1998)

Thistoll, T., Hooper, V., Pauleen, D.J.: Acquiring and developing theoretical sensitivity through undertaking a grounded preliminary literature review. Qual. Quant. 50 (2), 619–636 (2016)

Tobi, H., Kampen, J.K.: Research design: the methodology for interdisciplinary research framework. Qual. Quant. 52 , 1209–1225 (2018)

Tomaszewski, L.E., Zarestky, J., Gonzalez, E.: Planning qualitative research: design and decision making for new researchers. Int J Qual Methods 19 , 1–7 (2020)

Tranfield, D., Denyer, D., Smart, P.: Towards a methodology for developing evidence informed management knowledge by means of systematic review. Br. J. Manag. 14 (3), 207–222 (2003)

Travers, G.: New methods, old problems: a sceptical view of innovation in qualitative research. Qual. Res. 9 (2), 161–179 (2009)

Tzagkarakis, S.I., Kritas, D.: Mixed research methods in political science and governance: approaches and applications. Qual. Quant. 57 , 1–15 (2022)

Urquhart, C.: Grounded Theory for Qualitative Research: A Practical Guide. Sage, London (2013)

Book   Google Scholar  

Vasileiou, K., Barnett, J., Thorpe, S., Young, T.: Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med. Res. Methodol. 18 (1), 1–18 (2018)

Welch, C., Piekkari, R., Plakoyiannaki, E., Mantymaki, E.P.: Theorising from case studies: towards a pluralist future for international business research. J. Int. Bus. Stud. 42 (5), 1–24 (2011)

Wiles, R., Crow, G., Pain, H.: Innovation in qualitative research methods: a narrative review. Qual. Res. 11 (5), 587–604 (2011)

Yin, R.K.: Case Study Research: Design and Methods. Sage, London (2014)

Download references

Acknowledgements

I am indebted to Professor Ben Lupton, my PhD Director of Studies and Dr Valerie Antcliff my second PhD supervisor, for their mentorship over the years. I continue to draw on the wealth of knowledge they invested in me to generate knowledge. My profound gratitude also goes to the chief editor, associate editor and reviewers for this journal whose insightful review strengthened this article.

This methodology was formulated and executed in a PhD that was fully funded by the Manchester Metropolitan University, UK.

Author information

Authors and affiliations.

Decent Work and Productivity Research Centre, Manchester Metropolitan University, All Saints Building, Manchester, M15 6BH, UK

Charles Dahwa

You can also search for this author in PubMed   Google Scholar

Contributions

Dr CD is the sole author.

Corresponding author

Correspondence to Charles Dahwa .

Ethics declarations

Conflict of interest.

This article has not been submitted to any other academic journals.

Additional information

Publisher's note.

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

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Dahwa, C. Adapting and blending grounded theory with case study: a practical guide. Qual Quant (2023). https://doi.org/10.1007/s11135-023-01783-9

Download citation

Accepted : 27 October 2023

Published : 08 December 2023

DOI : https://doi.org/10.1007/s11135-023-01783-9

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

  • Grounded theory
  • Qualitative research
  • Qualitative inquiry
  • Find a journal
  • Publish with us
  • Track your research

U.S. flag

An official website of the United States government

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

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

  • Publications
  • Account settings
  • Advanced Search
  • Journal List
  • SAGE Open Nurs
  • v.7; Jan-Dec 2021

Case Study Analysis as an Effective Teaching Strategy: Perceptions of Undergraduate Nursing Students From a Middle Eastern Country

Vidya seshan.

1 Maternal and Child Health Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Gerald Amandu Matua

2 Fundamentals and Administration Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Divya Raghavan

Judie arulappan, iman al hashmi, erna judith roach, sheeba elizebath sunderraj, emi john prince.

3 Griffith University, Nathan Campus, Queensland 4111

Background: Case study analysis is an active, problem-based, student-centered, teacher-facilitated teaching strategy preferred in undergraduate programs as they help the students in developing critical thinking skills. Objective: It determined the effectiveness of case study analysis as an effective teacher-facilitated strategy in an undergraduate nursing program. Methodology: A descriptive qualitative research design using focus group discussion method guided the study. The sample included undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018. The researcher used a purposive sampling technique and a total of 22 students participated in the study, through five (5) focus groups, with each focus group comprising between four to six nursing students. Results: In total, nine subthemes emerged from the three themes. The themes were “Knowledge development”, “Critical thinking and Problem solving”, and “Communication and Collaboration”. Regarding “Knowledge development”, the students perceived case study analysis method as contributing toward deeper understanding of the course content thereby helping to reduce the gap between theory and practice especially during clinical placement. The “Enhanced critical thinking ability” on the other hand implies that case study analysis increased student's ability to think critically and aroused problem-solving interest in the learners. The “Communication and Collaboration” theme implies that case study analysis allowed students to share their views, opinions, and experiences with others and this enabled them to communicate better with others and to respect other's ideas which further enhanced their team building capacities. Conclusion: This method is effective for imparting professional knowledge and skills in undergraduate nursing education and it results in deeper level of learning and helps in the application of theoretical knowledge into clinical practice. It also broadened students’ perspectives, improved their cooperation capacity and their communication with each other. Finally, it enhanced student's judgment and critical thinking skills which is key for their success.

Introduction/Background

Recently, educators started to advocate for teaching modalities that not only transfer knowledge ( Shirani Bidabadi et al., 2016 ), but also foster critical and higher-order thinking and student-centered learning ( Wang & Farmer, 2008 ; Onweh & Akpan, 2014). Therefore, educators need to utilize proven teaching strategies to produce positive outcomes for learners (Onweh & Akpan, 2014). Informed by this view point, a teaching strategy is considered effective if it results in purposeful learning ( Centra, 1993 ; Sajjad, 2010 ) and allows the teacher to create situations that promote appropriate learning (Braskamp & Ory, 1994) to achieve the desired outcome ( Hodges et al., 2020 ). Since teaching methods impact student learning significantly, educators need to continuously test the effectives of their teaching strategies to ensure desired learning outcomes for their students given today's dynamic learning environments ( Farashahi & Tajeddin, 2018 ).

In this study, the researchers sought to study the effectiveness of case study analysis as an active, problem-based, student-centered, teacher-facilitated strategy in a baccalaureate-nursing program. This choice of teaching method is supported by the fact that nowadays, active teaching-learning is preferred in undergraduate programs because, they not only make students more powerful actors in professional life ( Bean, 2011 ; Yang et al., 2013 ), but they actually help learners to develop critical thinking skills ( Clarke, 2010 ). In fact, students who undergo such teaching approaches usually become more resourceful in integrating theory with practice, especially as they solve their case scenarios ( Chen et al., 2019 ; Farashahi & Tajeddin, 2018 ; Savery, 2019 ).

Review of Literature

As a pedagogical strategy, case studies allow the learner to integrate theory with real-life situations as they devise solutions to the carefully designed scenarios ( Farashahi & Tajeddin, 2018 ; Hermens & Clarke, 2009). Another important known observation is that case-study-based teaching exposes students to different cases, decision contexts and the environment to experience teamwork and interpersonal relations as “they learn by doing” thus benefiting from possibilities that traditional lectures hardly create ( Farashahi & Tajeddin, 2018 ; Garrison & Kanuka, 2004 ).

Another merit associated with case study method of teaching is the fact that students can apply and test their perspectives and knowledge in line with the tenets of Kolb et al.'s (2014) “experiential learning model”. This model advocates for the use of practical experience as the source of one's learning and development. Proponents of case study-based teaching note that unlike passive lectures where student input is limited, case studies allow them to draw from their own experience leading to the development of higher-order thinking and retention of knowledge.

Case scenario-based teaching also encourages learners to engage in reflective practice as they cooperate with others to solve the cases and share views during case scenario analysis and presentation ( MsDade, 1995 ).

This method results in “idea marriage” as learners articulate their views about the case scenario. This “idea marriage” phenomenon occurs through knowledge transfer from one situation to another as learners analyze scenarios, compare notes with each other, and develop multiple perspectives of the case scenario. In fact, recent evidence shows that authentic case-scenarios help learners to acquire problem solving and collaborative capabilities, including the ability to express their own views firmly and respectfully, which is vital for future success in both professional and personal lives ( Eronen et al., 2019 ; Yajima & Takahashi, 2017 ). In recognition of this higher education trend toward student-focused learning, educators are now increasingly expected to incorporate different strategies in their teaching.

This study demonstrated that when well implemented, educators can use active learning strategies like case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. This study is significant because the findings will help educators in the country and in the region to incorporate active learning strategies such as case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. Besides, most studies on the case study method in nursing literature mostly employ quantitative methods. The shortage of published research on the case study method in the Arabian Gulf region and the scanty use of qualitative methods further justify why we adopted the focus group method for inquiry.

A descriptive qualitative research design using focus group discussion method guided the study. The authors chose this method because it is not only inexpensive, flexible, stimulating but it is also known to help with information recall and results in rich data ( Matua et al., 2014 ; Streubert & Carpenter, 2011 ). Furthermore, as evidenced in the literature, the focus group discussion method is often used when there is a need to gain an in-depth understanding of poorly understood phenomena as the case in our study. The choice of this method is further supported by the scarcity of published research related to the use of case study analysis as a teaching strategy in the Middle Eastern region, thereby further justifying the need for an exploratory research approach for our study.

As a recommended strategy, the researchers generated data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and cased-based teaching approaches. The focus group interviews allowed the study participants to express their experiences and perspectives in their own words. In addition, the investigators integrated participants’ self-reported experiences with their own observations and this enhanced the study findings ( Morgan & Bottorff, 2010 ; Nyumba et al., 2018 ; Parker & Tritter, 2006 ).

Eligibility Criteria

In order to be eligible to participate in the study, the participants had to:

  • be a baccalaureate nursing student in College of Nursing, Sultan Qaboos University
  • register for Maternity Nursing Course in 2017 and 2018.
  • attend all the Case Study Analysis sessions in the courses before the study.
  • show a willingness to participate in the study voluntarily and share their views freely.

The population included the undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018.

The researcher used a purposive sampling technique to choose participants who were capable of actively participating and discussing their views in the focus group interviews. This technique enabled the researchers to select participants who could provide rich information and insights about case study analysis method as an effective teaching strategy. The final study sample included baccalaureate nursing students who agreed to participate in the study by signing a written informed consent. In total, twenty-two (22) students participated in the study, through five focus groups, with each focus group comprising between four and six students. The number of participants was determined by the stage at which data saturation was reached. The point of data saturation is when no new information emerges from additional participants interviewed ( Saunders et al., 2018 ).Focus group interviews were stopped once data saturation was achieved. Qualitative research design with focus group discussion allowed the researchers to generate data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and case-based teaching approaches. The focus group interviews allowed the study participants to express their perspectives in their own words. In addition, the investigators enhanced the study findings by integrating participants’ self-reported experiences with the researchers’ own observations and notes during the study.

The study took place at College of Nursing; Sultan Qaboos University, Oman's premier public university, in Muscat. This is the only setting chosen for the study. The participants are the students who were enrolled in Maternal Health Nursing course during 2017 and 2018. The interviews occurred in the teaching rooms after official class hours. Students who did not participate in the study learnt the course content using the traditional lecture based method.

Ethical Considerations

Permission to conduct the study was granted by the College Research and Ethics Committee (XXXX). Prior to the interviews, each participant was informed about the purpose, benefits as well as the risks associated with participating in the study and clarifications were made by the principal researcher. After completing this ethical requirement, each student who accepted to participate in the study proceeded to sign an informed consent form signifying that their participation in the focus group interview was entirely voluntary and based on free will.

The anonymity of study participants and confidentiality of their data was upheld throughout the focus group interviews and during data analysis. To enhance confidentiality and anonymity of the data, each participant was assigned a unique code number which was used throughout data analysis and reporting phases. To further assure the confidentiality of the research data and anonymity of the participants, all research-related data were kept safe, under lock and key and through digital password protection, with unhindered access only available to the research team.

Research Intervention

In Fall 2017 and Spring 2018 semesters, as a method of teaching Maternal Health Nursing course, all students participated in two group-based case study analysis exercises which were implemented in the 7 th and 13 th weeks. This was done after the students were introduced to the case study method using a sample case study prior to the study. The instructor explained to the students how to solve the sample problem, including how to accomplish the role-specific competencies in the courses through case study analysis. In both weeks, each group consisting of six to seven students was assigned to different case scenarios to analyze and work on, after which they presented their collective solution to the case scenarios to the larger class of 40 students. The case scenarios used in both weeks were peer-reviewed by the researchers prior to the study.

Pilot Study

A group of three students participated as a pilot group for the study. However, the students who participated in the pilot study were not included in the final study as is general the principle with qualitative inquiry because of possible prior exposure “contamination”. The purpose of piloting was to gather data to provide guidance for a substantive study focusing on testing the data collection procedure, the interview process including the sequence and number of questions and probes and recording equipment efficacy. After the pilot phase, the lessons learned from the pilot were incorporated to ensure smooth operations during the actual focus group interview ( Malmqvist et al., 2019 .

Data Collection

The focus group interviews took place after the target population was exposed to case study analysis method in Maternal Health Nursing course during the Fall 2017 and Spring 2018 semesters. Before data collection began, the research team pilot tested the focus group interview guide to ensure that all the guide questions were clear and well understood by study participants.

In total, five (5) focus groups participated in the study, with each group comprising between four and six students. The focus group interviews lasted between 60 and 90 min. In addition to the interview guide questions, participants’ responses to unanswered questions were elicited using prompts to facilitate information flow whenever required. As a best practice, all the interviews were audio-recorded in addition to extensive field notes taken by one of the researchers. The focus group interviews continued until data saturation occurred in all the five (5) focus groups.

Credibility

In this study, participant's descriptions were digitally audio recorded to ensure that no information was lost. In order to ensure that the results are accurate, verbatim transcriptions of the audio recordings were done supported by interview notes. Furthermore, interpretations of the researcher were verified and supported with existing literature with oversight from the research team.

Transferability

The researcher provided a detailed description about the study settings, participants, sampling technique, and the process of data collection and analyses. The researcher used verbatim quotes from various participants to aid the transferability of the results.

Dependability

The researcher ensured that the research process is clearly documented, traceable, and logical to achieve dependability of the research findings. Furthermore, the researcher transparently described the research steps, procedures and process from the start of the research project to the reporting of the findings.

Confirmability

In this study, confirmability of the study findings was achieved through the researcher's efforts to make the findings credible, dependable, and transferable.

Data Analysis

Data were analyzed manually after the lead researcher integrated the verbatim transcriptions with the extensive field notes to form the final data set. Data were analyzed thematically under three thematic areas of a) knowledge development; b) critical thinking and problem solving; and (c) communication and collaboration, which are linked to the study objectives. The researchers used the Six (6) steps approach to conduct a trustworthy thematic analysis: (1) familiarization with the research data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining and naming themes, (6) writing the report ( Nowell et al., 2017 ).

The analysis process started with each team member individually reading and re-reading the transcripts several times and then identifying meaning units linked to the three thematic areas. The co-authors then discussed in-depth the various meaning units linked to the thematic statements until consensus was reached and final themes emerged based on the study objectives.

A total of 22 undergraduate third-year baccalaureate nursing students who were enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018 participated in the study, through five focus groups, with each group comprising four to six students. Of these, 59% were females and 41% were males. In total, nine subthemes emerged from the three themes. Under knowledge development, emerged the subthemes, “ deepened understanding of content ; “ reduced gap between theory and practice” and “ improved test-taking ability ”. While under Critical thinking and problem solving, emerged the subthemes, “ enhanced critical thinking ability ” and “ heightened curiosity”. The third thematic area of communication and collaboration yielded, “ improved communication ability ”; “ enhanced team-building capacity ”; “ effective collaboration” and “ improved presentation skills ”, details of which are summarized in Table 1 .

Table 1.

Objective Linked Themes and Student Perceptions of Outcome Case Study Analysis.

Theme 1: Knowledge Development

In terms of knowledge development, students expressed delight at the inclusion of case study analysis as a method during their regular theory class. The first subtheme related to knowledge development that supports the adoption of the case study approach is its perceived benefit of ‘ deepened understanding of content ’ by the students as vividly described by this participant:

“ I was able to perform well in the in-course exams as this teaching method enhanced my understanding of the content rather than memorizing ” (FGD#3).

The second subtheme related to knowledge development was informed by participants’ observation that teaching them using case study analysis method ‘ reduced the gap between theory and practice’. This participant's claim stem from the realization that, a case study scenario his group analyzed in the previous week helped him and his colleagues to competently deal with a similar situation during clinical placement the following week, as articulated below:

“ You see when I was caring for mothers in antenatal unit, I could understand the condition better and could plan her care well because me and my group already analyzed a similar situation in class last week which the teacher gave us, this made our work easier in the ward”. (FGD#7).

Another student added that:

“ It was useful as what is taught in the theory class could be applied to the clinical cases.”

This ‘theory-practice’ connection was particularly useful in helping students to better understand how to manage patients with different health conditions. Interestingly, the students reported that they were more likely to link a correct nursing care plan to patients whose conditions were close to the case study scenarios they had already studied in class as herein affirmed:

“ …when in the hospital I felt I could perceive the treatment modality and plan for [a particular] nursing care well when I [had] discussed with my team members and referred the textbook resource while performing case study discussion”. (FGD#17).

In a similar way, another student added:

“…I could relate with the condition I have seen in the clinical area. So this has given me a chance to recall the condition and relate the theory to practice”. (FGD#2) .

The other subtheme closely related to case study scenarios as helping to deepen participant's understanding of the course content, is the notion that this teaching strategy also resulted in ‘ improved test taking-ability’ as this participant's verbatim statement confirms:

“ I could answer the questions related to the cases discussed [much] better during in-course exams. Also [the case scenarios] helped me a great deal to critically think and answer my exam papers” (FGD#11).

Theme 2: Critical Thinking and Problem Solving

In this subtheme, students found the case study analysis as an excellent method to learn disease conditions in the two courses. This perceived success with the case study approach is associated with the method's ability to ‘ enhance students’ critical thinking ability’ as this student declares:

“ This method of teaching increased my ability to think critically as the cases are the situations, where we need to think to solve the situation”. (FGD#5)

This enhanced critical thinking ability attributed to case study scenario analysis was also manifested during patient care where students felt it allowed them to experience a “ flow of patient care” leading to better patient management planning as would typically occur during case scenario analysis. In support of this finding, a participant mentioned that:

“ …I could easily connect the flow of patient care provided and hence was able to plan for [his] management as often required during case study discussion” (FGD#12)

Another subtheme linked with this theme is the “ heightened curiosity” associated with the case scenario discussions. It was clear from the findings that the cases aroused curiosity in the mind of the students. This heightened interest meant that during class discussion, baccalaureate nursing students became active learners, eager to discover the next set of action as herein affirmed:

“… from the beginning of discussion with the group, I was eager to find the answer to questions presented and wanted to learn the best way for patient management” (FGD#14)

Theme 3: Communication and Collaboration

In terms of its impact on student communication, the subtheme revealed that case study analysis resulted in “ improved communication ability” among the nursing students . This enhanced ability of students to exchange ideas with each other may be attributed to the close interaction required to discuss and solve their assigned case scenarios as described by the participant below:

“ as [case study analysis] was done in the way of group discussion, I felt me and my friends communicated more within the group as we discussed our condition. We also learnt from each other, and we became better with time.” (FGD#21).

The next subtheme further augments the notion that case study analysis activities helped to “ enhance team-building capacity” of students as this participant affirmatively narrates:

“ students have the opportunity to meet face to face to share their views, opinion, and their experience, as this build on the way they can communicate with each other and respect each other's opinions and enhance team-building”. (FGD#19).

Another subtheme revealed from the findings show that the small groups in which the case analysis occurs allowed the learners to have deeper and more focused conversations with one another, resulting in “ an effective collaboration between students” as herein declared:

“ We could collaborate effectively as we further went into a deep conversation on the case to solve”. (FGD#16).

Similarly, another student noted that:

“ …discussion of case scenarios helped us to prepare better for clinical postings and simulation lab experience” (FGD#5) .

A fourth subtheme related to communication found that students also identified that case study analysis resulted in “ improved presentation skills”. This is attributed in part to the preparation students have to go through as part of their routine case study discussion activities, which include organizing their presentations and justifying and integrating their ideas. Besides readying themselves for case presentations, the advice, motivation, and encouragement such students receive from their faculty members and colleagues makes them better presenters as confirmed below:

“ …teachers gave us enough time to prepare, hence I was able to present in front of the class regarding the finding from our group.” (FGD#16).

In this study, the researches explored learner's perspectives on how one of the active teaching strategies, case study analysis method impacted their knowledge development, critical thinking, and problem solving as well as communication and collaboration ability.

Knowledge Development

In terms of knowledge development, the nursing students perceived case study analysis as contributing toward: (a) deeper understanding of content, (b) reducing gap between theory and practice, and (c) improving test-taking ability. Deeper learning” implies better grasping and retention of course content. It may also imply a deeper understanding of course content combined with learner's ability to apply that understanding to new problems including grasping core competencies expected in future practice situations (Rickles et al., 2019; Rittle-Johnson et al., 2020 ). Deeper learning therefore occurs due to the disequilibrium created by the case scenario, which is usually different from what the learner already knows ( Hattie, 2017 ). Hence, by “forcing” students to compare and discuss various options in the quest to solve the “imbalance” embedded in case scenarios, students dig deeper in their current understanding of a given content including its application to the broader context ( Manalo, 2019 ). This movement to a deeper level of understanding arises from carefully crafted case scenarios that instructors use to stimulate learning in the desired area (Nottingham, 2017; Rittle-Johnson et al., 2020 ). The present study demonstrated that indeed such carefully crafted case study scenarios did encourage students to engage more deeply with course content. This finding supports the call by educators to adopt case study as an effective strategy.

Another finding that case study analysis method helps in “ reducing the gap between theory and practice ” implies that the method helps students to maintain a proper balance between theory and practice, where they can see how theoretical knowledge has direct practical application in the clinical area. Ajani and Moez (2011) argue that to enable students to link theory and practice effectively, nurse educators should introduce them to different aspects of knowledge and practice as with case study analysis. This dual exposure ensures that students are proficient in theory and clinical skills. This finding further amplifies the call for educators to adequately prepare students to match the demands and realities of modern clinical environments ( Hickey, 2010 ). This expectation can be met by ensuring that student's knowledge and skills that are congruent with hospital requirements ( Factor et al., 2017 ) through adoption of case study analysis method which allows integration of clinical knowledge in classroom discussion on regular basis.

The third finding, related to “improved test taking ability”, implies that case study analysis helped them to perform better in their examination, noting that their experience of going through case scenario analysis helped them to answer similar cases discussed in class much better during examinations. Martinez-Rodrigo et al. (2017) report similar findings in a study conducted among Spanish electrical engineering students who were introduced to problem-based cooperative learning strategies, which is similar to case study analysis method. Analysis of student's results showed that their grades and pass rates increased considerably compared to previous years where traditional lecture-based method was used. Similar results were reported by Bonney (2015) in an even earlier study conducted among biology students in Kings Borough community college students, in New York, United States. When student's performance in examination questions covered by case studies was compared with class-room discussions, and text-book reading, case study analysis approach was significantly more effective compared to traditional methods in aiding students’ performance in their examinations. This finding therefore further demonstrates that case study analysis method indeed improves student's test taking ability.

Critical Thinking and Problem Solving

In terms of critical thinking and problem-solving ability, the use of case study analysis resulted in two subthemes: (a) enhanced critical thinking ability and (b) heightened learner curiosity. The “ enhanced critical thinking ability” implies that case analysis increased student's ability to think critically as they navigated through the case scenarios. This observation agrees with the findings of an earlier questionnaire-based study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh, that showed 81% of respondents agree that case study analysis develops critical thinking ability and enables students to do better problem analysis ( Muhiuddin & Jahan, 2006 ). This observation agrees with the findings of an earlier study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh. The study showed that 81% of respondents agreed that case study analysis facilitated the development of critical thinking ability in the learners and enabled the students to perform better with problem analysis ( Muhiuddin & Jahan, 2006 ).

More recently, Suwono et al. (2017) found similar results in a quasi-experimental research conducted at a Malaysian university. The research findings showed that there was a significant difference in biological literacy and critical thinking skills between the students taught using socio-biological case-based learning and those taught using traditional lecture-based learning. The researchers concluded that case-based learning enhanced the biological literacy and critical thinking skills of the students. The current study adds to the existing pedagogical knowledge base that case study methodology can indeed help to deepen learner's critical thinking and problem solving ability.

The second subtheme related to “ heightened learner curiosity” seems to suggest that the case studies aroused problem-solving interest in learners. This observation agrees with two earlier studies by Tiwari et al. (2006) and Flanagan and McCausland (2007) who both reported that most students enjoyed case-based teaching. The authors add that the case study method also improved student's clinical reasoning, diagnostic interpretation of patient information as well as their ability to think logically when presented a challenge in the classroom and in the clinical area. Jackson and Ward (2012) similarly reported that first year engineering undergraduates experienced enhanced student motivation. The findings also revealed that the students venturing self-efficacy increased much like their awareness of the importance of key aspects of the course for their future careers. The authors conclude that the case-based method appears to motivate students to autonomously gather, analyze and present data to solve a given case. The researchers observed enhanced personal and collaborative efforts among the learners, including improved communication ability. Further still, learners were more willing to challenge conventional wisdom, and showed higher “softer” skills after exposure to case analysis based teaching method. These findings like that of the current study indicate that teaching using case based analysis approach indeed motivates students to engage more in their learning, there by resulting in deeper learning.

Communication and Collaboration

Case study analysis is also perceived to result in: (a) improved communication ability; (b) enhanced team -building capacity, (c) effective collaboration ability, and (d) enhanced presentation skills. The “ improved communication ability ” manifested in learners being better able to exchange ideas with peers, communicating their views more clearly and collaborating more effectively with their colleagues to address any challenges that arise. Fini et al. (2018) report comparable results in a study involving engineering students who were subjected to case scenario brainstorming activities about sustainability concepts and their implications in transportation engineering in selected courses. The results show that this intervention significantly improved student's communication skills besides their higher-order cognitive, self-efficacy and teamwork skills. The researchers concluded that involving students in brainstorming activities related to problem identification including their practical implications, is an effective teaching strategy. Similarly, a Korean study by Park and Choi (2018) that sought to analyze the effects of case-based communication training involving 112 sophomore nursing students concluded that case-based training program improved the students’ critical thinking ability and communication competence. This finding seems to support further the use of case based teaching as an effective teaching-learning strategy.

The “ enhanced team-building capacity” arose from the opportunity students had in sharing their views, opinions, and experiences where they learned to communicate with each other and respect each other's ideas which further enhance team building. Fini et al. (2018) similarly noted that increased teamwork levels were seen among their study respondents when the researchers subjected engineering students to case scenario based-brainstorming activities as occurs with case study analysis teaching. Likewise, Lairamore et al. (2013) report similar results in their study that showed that case study analysis method increased team work ability and readiness among students from five health disciplines in a US-based study.

The finding that case study analysis teaching method resulted in “ effective collaboration ability” among students manifested as students entered into deep conversation as they solved the case scenarios. Rezaee and Mosalanejad (2015) assert that such innovative learning strategies result in noticeable educational outcomes, such as greater satisfaction with and enjoyment of the learning process ( Wellmon et al., 2012 ). Further, positive attitudes toward learning and collaboration have been noted leading to deeper learning as students prepare for case discussions ( Rezaee & Mosalanejad, 2015 ). This results show that case study analysis can be utilized by educators to foster professional collaboration among their learners, which is one of the key expectations of new graduates today.

The finding associated with “improved presentation skills” is consistent with the results of a descriptive study in Saudi Arabia that compared case study and traditional lectures in the teaching of physiology course to undergraduate nursing students. The researchers found that case-based teaching improved student’ overall knowledge and performance in the course including facilitating the acquisition of skills compared to traditional lectures ( Majeed, 2014 ). Noblitt et al. (2010) report similar findings in their study that compares traditional presentation approach with the case study method for developing and improving student's oral communication skills. This finding extends our understanding that case study method improves learners’ presentation skills.

The study was limited to level third year nursing students belonging to only one college and the sample size, which might limit the transferability of the study findings to other settings.

Implications for Practice

These study findings add to the existing body of knowledge that places case study based teaching as a tested method that promotes perception learning where students’ senses are engaged as a result of the real-life and authentic clinical scenarios ( Malesela, 2009 ), resulting in deeper learning and achievement of long-lasting knowledge ( Fiscus, 2018 ). The students reported that case scenario discussions broadened their perspectives, improved their cooperation capacity and communication with each other. This teaching method, in turn, offers students an opportunity to enhance their judgment and critical thinking skills by applying theory into practice.

These skills are critically important because nurses need to have the necessary knowledge and skills to plan high quality care for their patients to achieve a speedy recovery. In order to attain this educational goal, nurse educators have to prepare students through different student- centered strategies. The findings of our study appear to show that when appropriately used, case-based teaching results in acquisition of disciplinary knowledge manifested by deepened understanding of course content, as well as reducing the gap between theory and practice and enhancing learner's test-taking-ability. The study also showed that cased based teaching enhanced learner's critical thinking ability and curiosity to seek and acquire a deeper knowledge. Finally, the study results indicate that case study analysis results in improved communication and enhanced team-building capacity, collaborative ability and improved oral communication and presentation skills. The study findings and related evidence from literature show that case study analysis is well- suited approach for imparting knowledge and skills in baccalaureate nursing education.

This study evaluated the usefulness of Case Study Analysis as a teaching strategy. We found that this method of teaching helps encourages deeper learning among students. For instructors, it provides the opportunity to tailor learning experiences for students to undertake in depth study in order to stimulate deeper understanding of the desired content. The researchers conclude that if the cases are carefully selected according to the level of the students, and are written realistically and creatively and the group discussions keep students well engaged, case study analysis method is more effective than other traditional lecture methods in facilitating deeper and transferable learning/skills acquisition in undergraduate courses.

Conflict of Interest: The authors declare no conflict of interest.

ORCID iD: Judie Arulappan https://orcid.org/0000-0003-2788-2755

  • Ajani K., Moez S. (2011). Gap between knowledge and practice in nursing . Procedia-Social and Behavioral Sciences , 15 , 3927–3931. 10.1016/j.sbspro.2011.04.396 [ CrossRef ] [ Google Scholar ]
  • Bean J. C. (2011). Engaging ideas: The professor’s guide to integrating writing critical thinking and active-learning in the classroom (2nd ed.). Jossey-Bass. [ Google Scholar ]
  • Bonney K. M. (2015). Case study teaching method improves student performance and perceptions of learning gains . Journal of Microbiology & Biology Education , 16 ( 1 ), 21–28. 10.1128/jmbe.v16i1.846 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Braskamp L. A., Ory J. C. (1994). Assessing faculty work: Enhancing individual and institutional performance . Jossey-Bass Higher and Adult Education Series. Jossey-Bass Inc. [ Google Scholar ]
  • Centra J. A. (1993). Reflective faculty evaluation: Enhancing teaching and determining faculty effectiveness . Jossey-Bass. [ Google Scholar ]
  • Chen W., Shah U. V., Brechtelsbauer C. (2019). A framework for hands-on learning in chemical engineering education—training students with the end goal in mind . Education for Chemical Engineers , 28 , 25–29. 10.1016/j.ece.2019.03.002 [ CrossRef ] [ Google Scholar ]
  • Clarke J. (2010). Student centered teaching methods in a Chinese setting . Nurse Education Today , 30 ( 1 ), 15–19. 10.1016/j.nedt.2009.05.009 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Eronen L., Kokko S., Sormunen K. (2019). Escaping the subject-based class: A Finnish case study of developing transversal competencies in a transdisciplinary course . The Curriculum Journal , 30 ( 3 ), 264–278. 10.1080/09585176.2019.1568271 [ CrossRef ] [ Google Scholar ]
  • Factor E. M. R., Matienzo E. T., de Guzman A. B. (2017). A square peg in a round hole: Theory-practice gap from the lens of Filipino student nurses . Nurse Education Today , 57 , 82–87. 10.1016/j.nedt.2017.07.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Farashahi M., Tajeddin M. (2018). Effectiveness of teaching methods in business education: A comparison study on the learning outcomes of lectures, case studies and simulations . The International Journal of Management Education , 16 ( 1 ), 131–142. 10.1016/j.ijme.2018.01.003 [ CrossRef ] [ Google Scholar ]
  • Fini E. H., Awadallah F., Parast M. M., Abu-Lebdeh T. (2018). The impact of project-based learning on improving student learning outcomes of sustainability concepts in transportation engineering courses . European Journal of Engineering Education , 43 ( 3 ), 473–488. 10.1080/03043797.2017.1393045 [ CrossRef ] [ Google Scholar ]
  • Fiscus J. (2018). Reflection in Motion: A Case Study of Reflective Practice in the Composition Classroom [ Doctoral dissertation ]. Source: http://hdl.handle.net/1773/42299 [ Google Scholar ]
  • Flanagan N. A., McCausland L. (2007). Teaching around the cycle: Strategies for teaching theory to undergraduate nursing students . Nursing Education Perspectives , 28 ( 6 ), 310–314. [ PubMed ] [ Google Scholar ]
  • Garrison D. R., Kanuka H. (2004). Blended learning: Uncovering its transformative potential in higher education . The internet and higher education , 7 ( 2 ), 95–105. 10.1016/j.iheduc.2004.02.001 [ CrossRef ] [ Google Scholar ]
  • Hattie J. (2017). Foreword . In Nottingham J. (Ed.), The learning challenge: How to guide your students through the learning pit to achieve deeper understanding . Corwin Press, p. xvii. [ Google Scholar ]
  • Hermens A., Clarke E. (2009). Integrating blended teaching and learning to enhance graduate attributes . Education+ Training , 51 ( 5/6 ), 476–490. [ Google Scholar ]
  • Hickey M. T. (2010). Baccalaureate nursing graduates’ perceptions of their clinical instructional experiences and preparation for practice . Journal of Professional Nursing , 26 ( 1 ), 35–41. 10.1016/j.profnurs.2009.03.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Hodges C., Moore S., Lockee B., Trust T., Bond A. (2020). The difference between emergency remote teaching and online learning . Educause review , 27 , 1–12. [ Google Scholar ]
  • Jackson N. R., Ward A. E. (2012). Curiosity based learning: Impact study in 1st year electronics undergraduates. 2012 International Conference on Information Technology Based Higher Education and Training (ITHET), Istanbul, pp. 1–6. 10.1109/ITHET.2012.6246005. [ CrossRef ] [ Google Scholar ]
  • Kolb A. Y., Kolb D. A., Passarelli A., Sharma G. (2014). On becoming an experiential educator: The educator role profile . Simulation & Gaming , 45 ( 2 ), 204–234. 10.1177/1046878114534383 [ CrossRef ] [ Google Scholar ]
  • Lairamore C., George-Paschal L., McCullough K., Grantham M., Head D. (2013). A case-based interprofessional education forum improves students’ perspectives on the need for collaboration, teamwork, and communication . MedEdPORTAL, The Journal of Teaching and learning resources , 9 , 10.15766/mep_2374-8265.9484 [ CrossRef ] [ Google Scholar ]
  • Majeed F. (2014). Effectiveness of case based teaching of physiology for nursing students . Journal of Taibah University Medical Sciences , 9 ( 4 ), 289–292. 10.1016/j.jtumed.2013.12.005 [ CrossRef ] [ Google Scholar ]
  • Malesela J. M. (2009). Case study as a learning opportunity among nursing students in a university . Health SA Gesondheid (Online) , 14 ( 1 ), 33–38. 10.4102/hsag.v14i1.434 [ CrossRef ] [ Google Scholar ]
  • Malmqvist J., Hellberg K., Möllås G., Rose R., Shevlin M. (2019). Conducting the pilot study: A neglected part of the research process? Methodological findings supporting the importance of piloting in qualitative research studies . International Journal of Qualitative Methods , 18 . 10.1177/1609406919878341 [ CrossRef ] [ Google Scholar ]
  • Manalo E. (ed.). (2019). Deeper learning, dialogic learning, and critical thinking: Research-based strategies for the classroom . Routledge. [ Google Scholar ]
  • Martinez-Rodrigo F., Herrero-De Lucas L. C., De Pablo S., Rey-Boue A. B. (2017). Using PBL to improve educational outcomes and student satisfaction in the teaching of DC/DC and DC/AC converters . IEEE Transactions on Education , 60 ( 3 ), 229–237. 10.1109/TE.2016.2643623 [ CrossRef ] [ Google Scholar ]
  • Matua G. A., Seshan V., Akintola A. A., Thanka A. N. (2014). Strategies for providing effective feedback during preceptorship: Perspectives from an Omani Hospital . Journal of Nursing Education and Practice , 4 ( 10 ), 24. 10.5430/jnep.v4n10p24 [ CrossRef ] [ Google Scholar ]
  • Morgan D. L., Bottorff J. L. (2010). Advancing our craft: Focus group methods and practice . Qualitative Health Research , 20 ( 5 ), 579–581. 10.1177/1049732310364625 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • MsDade S. A. (1995). Case study pedagogy to advance critical thinking . Teaching psychology , 22 ( 1 ), 9–10. 10.1207/s15328023top2201_3 [ CrossRef ] [ Google Scholar ]
  • Muhiuddin G., Jahan N. (2006). Students’ perception towards case study as a method of learning in the field of business administration’ . The Chittagong University Journal of Business Administration , 21 , 25–41. [ Google Scholar ]
  • Noblitt L., Vance D. E., Smith M. L. D. (2010). A comparison of case study and traditional teaching methods for improvement of oral communication and critical-thinking skills . Journal of College Science Teaching , 39 ( 5 ), 26–32. [ Google Scholar ]
  • Nottingham J. (2017). The learning challenge: How to guide your students through the learning pit to achieve deeper understanding . Corwin Press. [ Google Scholar ]
  • Nowell L. S., Norris J. M., White D. E., Moules N. J. (2017). Thematic analysis: Striving to meet the trustworthiness criteria . International Journal of Qualitative Methods , 16 ( 1 ). 10.1177/1609406917733847 [ CrossRef ] [ Google Scholar ]
  • Nyumba T., Wilson K., Derrick C. J., Mukherjee N. (2018). The use of focus group discussion methodology: Insights from two decades of application in conservation . Methods in Ecology and evolution , 9 ( 1 ), 20–32. 10.1111/2041-210X.12860 [ CrossRef ] [ Google Scholar ]
  • Onweh V. E., Akpan U. T. (2014). Instructional strategies and students academic performance in electrical installation in technical colleges in Akwa Ibom State: Instructional skills for structuring appropriate learning experiences for students . International Journal of Educational Administration and Policy Studies , 6 ( 5 ), 80–86. [ Google Scholar ]
  • Park S. J., Choi H. S. (2018). The effect of case-based SBAR communication training program on critical thinking disposition, communication self-efficacy and communication competence of nursing students . Journal of the Korea Academia-Industrial Cooperation Society , 19 ( 11 ), 426–434. 10.5762/KAIS.2018.19.11.426 [ CrossRef ] [ Google Scholar ]
  • Parker A., Tritter J. (2006). Focus group method and methodology: Current practice and recent debate . International Journal of Research & Method in Education , 29 ( 1 ), 23–37. 10.1080/01406720500537304 [ CrossRef ] [ Google Scholar ]
  • Rezaee R., Mosalanejad L. (2015). The effects of case-based team learning on students’ learning, self-regulation and self-direction . Global Journal of Health Science , 7 ( 4 ), 295. 10.5539/gjhs.v7n4p295 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Rickles J., Zeiser K. L., Yang R., O’Day J., Garet M. S. (2019). Promoting deeper learning in high school: Evidence of opportunities and outcomes . Educational Evaluation and Policy Analysis , 41 ( 2 ), 214–234. [ Google Scholar ]
  • Rittle-Johnson B., Star J. R., Durkin K., Loehr A. (2020). Compare and discuss to promote deeper learning. Deeper learning, dialogic learning, and critical thinking: Research-based strategies for the classroom . Routlegde, p. 48. 10.4324/9780429323058-4 [ CrossRef ] [ Google Scholar ]
  • Sajjad S. (2010). Effective teaching methods at higher education level . Pakistan Journal of Special Education , 11 , 29–43. [ Google Scholar ]
  • Saunders B., Sim J., Kingstone T., Baker S., Waterfield J., Bartlam B., Burroughs H., Jinks C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization . Quality & Quantity , 52 ( 4 ), 1893–1907. 10.1007/s11135-017-0574-8 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Savery J. R. (2019). Comparative pedagogical models of problem based learning . The Wiley Handbook of Problem Based Learning , 81–104. 10.1002/9781119173243.ch4 [ CrossRef ] [ Google Scholar ]
  • Shirani Bidabadi N., Nasr Isfahani A., Rouhollahi A., Khalili R. (2016). Effective teaching methods in higher education: Requirements and barriers . Journal of Advances in Medical Education & Professionalism , 4 ( 4 ), 170–178. [ PMC free article ] [ PubMed ] [ Google Scholar ]
  • Streubert H. J., Carpenter D. R. (2011). Qualitative research in nursing: Advancing the humanistic imperative . Wolters Kluwer. [ Google Scholar ]
  • Suwono H., Pratiwi H. E., Susanto H., Susilo H. (2017). Enhancement of students’ biological literacy and critical thinking of biology through socio-biological case-based learning . JurnalPendidikan IPA Indonesia , 6 ( 2 ), 213–220. 10.15294/jpii.v6i2.9622 [ CrossRef ] [ Google Scholar ]
  • Tiwari A., Lai P., So M., Yuen K. (2006). A comparison of the effects of problem-based learning and lecturing on the development of students’ critical thinking . Medical Education , 40 ( 6 ), 547–554. 10.1111/j.1365-2929.2006.02481.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Wang V., Farmer L. (2008). Adult teaching methods in China and bloom's taxonomy . International Journal for the Scholarship of Teaching and Learning , 2 ( 2 ), n2. 10.20429/ijsotl.2008 [ CrossRef ] [ Google Scholar ]
  • Wellmon R., Gilin B., Knauss L., Linn M. I. (2012). Changes in student attitudes toward interprofessional learning and collaboration arising from a case-based educational experience . Journal of Allied Health , 41 ( 1 ), 26–34. [ PubMed ] [ Google Scholar ]
  • Yajima K., Takahashi S. (2017). Development of evaluation system of AL students . Procedia Computer Science , 112 , 1388–1395. 10.1016/j.procs.2017.08.056 [ CrossRef ] [ Google Scholar ]
  • Yang W. P., Chao C. S. C., Lai W. S., Chen C. H., Shih Y. L., Chiu G. L. (2013). Building a bridge for nursing education and clinical care in Taiwan—using action research and confucian tradition to close the gap . Nurse Education Today , 33 ( 3 ), 199–204. 10.1016/j.nedt.2012.02.016 [ PubMed ] [ CrossRef ] [ Google Scholar ]

CONCEPTUAL ANALYSIS article

A process-based approach to cognitive behavioral therapy: a theory-based case illustration.

\r\nClarissa W. Ong,*

  • 1 Department of Psychology, University of Toledo, Toledo, OH, United States
  • 2 Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States
  • 3 Department of Psychology, University of Nevada, Reno, Reno, NV, United States
  • 4 Department of Psychology, Philipps-Universität Marburg, Marburg, Germany

Despite the significant contribution of cognitive-behavioral therapy to effective treatment options for specific syndromes, treatment progress has been stagnating, with response rates plateauing over the past several years. This stagnation has led clinical researchers to call for an approach that instead focuses on processes of change and the individual in their particular context. Process-based therapy (PBT) is a general approach representing a model of models, grounded in evolution science, with an emphasis on idiographic methods, network models of case conceptualization, and enhancing wellbeing. In this paper, we describe the theory underlying PBT and present a case study for how to apply PBT tools and principles to deliver process-informed and person-centered evidence-based treatment. In addition, we discuss lessons learned from our case and provide suggestions for future considerations when implementing PBT in clinical settings.

Introduction

Historical dominance of cognitive-behavioral therapy.

For decades, cognitive-behavioral therapy (CBT) has been the gold standard of evidence-based care for many mental illnesses as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), ranging from generalized anxiety disorder to eating disorders ( Covin et al., 2008 ; Linardon et al., 2017 ). CBT, in turn, has built its credibility on copious data accrued from the gold standard of clinical experimental design: randomized controlled trials. The most basic design of a randomized controlled trial entails comparing the means of two groups of randomly assigned people after one group receives the active intervention and the second does not. If the treatment group mean is found to be “significantly” better than that of the control group, statistically speaking, the treatment is deemed efficacious.

Data from hundreds of randomized controlled trials have shown that protocol-based CBT leads to more symptom improvement on average compared to other interventions (e.g., Butler et al., 2006 ; Hofmann et al., 2012 ). In addition, adjunctive treatment components are constantly tested to facilitate incremental gains from CBT, such as adding motivational interviewing ( Marker and Norton, 2018 ) or contingency management ( Worden et al., 2017 ). Prevailing wisdom over the past few decades declared that CBT tailored to specific disorders and randomized controlled trials are the solution to mental health struggles, and most clinical research and funding accordingly have operated on this assumption ( Chambless and Hollon, 1998 ; Tolin, 2020 ).

At the same time, treatment progress has been stagnating. CBT response rates have hovered around 50% for anxiety disorders for years ( Loerinc et al., 2015 ; Springer et al., 2018 ), suggesting that the gold standard is not getting better, despites decades and millions of dollars of research. Furthermore, relevance of the nomothetic principles underlying randomized controlled trials to individual wellbeing is tenuous, calling into question the utility of randomized controlled trials as a means of evaluating treatment efficacy and the generalizability of study findings to individual clients ( Molenaar, 2004 ). If the solution is not CBT protocols for disorders and randomized controlled trials, then we need to look elsewhere to ensure that clinical psychological science can adequately meet the needs of those who are suffering.

Move toward personalized care

Over the past few decades, there has been a growing movement toward using idiographic methods (or methods that focus in the individual and their functioning rather than groups and averages) in clinical psychology research, with the ultimate objective of personalizing psychotherapy for every client ( Rubel et al., 2018 ; Fisher et al., 2019 ; Levinson et al., 2021 ). Broadly speaking, idiographic treatment research strives to answer Paul’s famous question, “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (p. 111, Paul, 1967 ). For example, Levinson et al. (2021) identified central symptoms in individual-level networks among participants with eating disorders, then developed treatment plans by selecting corresponding modules from evidence-based treatments (e.g., emotion regulation module from dialectical behavior therapy [DBT] for feelings of shame and guilt).

Closely related to idiographic methods is a network approach to understanding psychopathology, which posits that symptoms have causal interrelationships with each other rather than are caused by a latent disease as assumed by the biomedical model ( Bringmann et al., 2022 ). Together, these ideas reflect a conceptualization of psychopathology as networks of interrelated biopsychosocial processes and problems that form a causal and dynamic network in ways unique to each person. Thus, even if two people present to therapy with a similar complaint, their prescribed treatments may vary depending on the person’s individual network of ways of addressing problems this is causing or maintaining this complaint ( Levinson et al., 2021 ).

Development of process-based therapy

Against the backdrop of burgeoning interest in idiographic and network-based clinical research ( Piccirillo et al., 2019 ), a new model of personalized evidence-based psychological treatment has emerged: process-based therapy (PBT; Hofmann and Hayes, 2019 ; Hayes et al., 2020a ). PBT is a general approach to clinical assessment, conceptualization, and treatment, representing a model of models . PBT is not a new therapy. Rather, it is a new framework to organize evidence-based therapeutic techniques—already known to psychologists—along basic psychological dimensions relevant to human adaptation to a given context, including cognition, attention, affect, behavior, self, and motivation, as well as biophysiological and sociocultural levels ( Hayes et al., 2022 ).

The dimensional model undergirding PBT is called the extended evolutionary meta-model or EEMM (rhymes with “dream;” Hayes et al., 2020b ). Its job is to clarify the inter-relatedness among processes with respect to EEMM dimensions and levels and to facilitate finding optimal therapeutic strategies to target the most relevant processes. Analogous to a closet, the EEMM provides space to consider different aspects of one’s psychological repertoire. In much the same way that a closet is rendered useful by the clothing it contains, the utility of the EEMM ultimately depends on the existence of meaningful content but it can be considered independently of content.

Along with the EEMM, PBT provides tools for idiographic assessment to guide treatment planning for the individual-in-context. These tools begin with a network approach wherein clinicians identify key variables relevant to the client’s presenting problem and hypothesize about how these variables relate to one another. Using PBT graphic conventions ( Hofmann et al., 2021 ), the direction and strength of the relationships are represented by opacity and size of arrowheads, respectively. For example, in Figure 1 , the network shows that the core belief, “I am a bad person” is hypothesized to lead the client to experience feelings of worthless and guilt, low mood, and low motivation to engage in hobbies (excitatory effect depicted with opaque arrowhead), with a stronger hypothesized effect on feelings of worthless and guilt. In contrast, modifying core beliefs is thought to have an inhibitory effect on the original core belief, as illustrated with a blank arrowhead, meaning that modifying core beliefs weakens the influence of the thought, “I am a bad person,” along with corresponding downstream effects.

www.frontiersin.org

Figure 1. Example of network model for a specific client. Extended evolutionary meta-model (EEMM) dimensions represented by each node are bolded. Size of the arrowheads indicates hypothesized strength of the relationship (bigger arrowheads = stronger correlation), and opacity reflects direction of the relationship (opaque = positive/excitatory, transparent = negative/inhibitory).

The intended function of PBT is to provide a theoretically coherent framework broad enough to encompass the gamut of psychotherapy orientations and furnish a lingua franca with which psychologists can use to communicate seemingly disparate ideas. Accordingly, PBT is grounded in evolution science, precisely because evolutionary principles have been postulated as a unifying theoretical framework across virtually all life science disciplines, including psychology ( Mesoudi et al., 2006 ; Hayes and Sanford, 2015 ). PBT views psychopathology as maladaptation to a given context due to problems in variation, selection, and retention of biopsychosocial processes in multiple dimensions and levels ( Hayes et al., 2020b ). While considering the complexity and interconnectedness of problems, clinicians strive to perturbate the client’s maladaptive network of such processes while building an adaptive, self-sustaining alternative network. This is done by applying specific treatment kernels that introduce new responding (variation), identify which strategies are most adaptive for a client given their goals (selection), help clients persist in useful responding (retention), across various psychological facets (dimensions), on intrapersonal and interpersonal scales (levels), in ways that are sensitive to history, situational demands and personally relevant aspirations (context).

Although PBT emphasizes idiographic methods and network models of case conceptualization, similar to other approaches observed in clinical psychology ( Fisher et al., 2019 ; Levinson et al., 2021 ), it goes beyond methodology. It also takes an explicit philosophical stance against diagnostic and symptom-driven models, instead directing efforts toward understanding clinically relevant processes and enhancing wellbeing , embodying a clear departure from randomized controlled trials and the symptom-focused tradition of clinical psychology. In other words, idiographic research focused on symptoms alone is still inadequate from a PBT perspective.

Rather, PBT entails attention to processes of change unique to the individual in their context over symptoms enumerated in a diagnostic manual (e.g., in the context of social anxiety and fear of negative judgment about physical appearance due to childhood bullying and emphasis on physical appearance in family of origin vs. fear of negative evaluation). Extending Paul’s classic question with a demand for precision, PBT instead asks, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?” (p. 2, Hayes et al., 2020a ). In a way, for PBT, personalizing treatment is not an end in itself, but a means to the end of developing more effective and efficient treatments for all individuals given limited available resources.

Given its explicit philosophical and methodological stance, PBT has the potential to undermine the barriers presently facing treatment development in two ways: ( Covin et al., 2008 ) it targets processes of change, not symptoms, and ( Linardon et al., 2017 ) it is evaluated on the level of the individual not only the group. That is, PBT is not diagnosis-specific and hence flexible enough to be used with presentations poorly captured by DSM diagnoses (e.g., multiple co-occurring diagnoses). PBT also considers individual differences and prioritizes what works for a person in their unique context, rather than an illusory average. Moreover, the goal of PBT is to improve wellbeing not symptom reduction, the default metric against which most evidence-based psychotherapies to date have been evaluated ( Linardon et al., 2017 ; Springer et al., 2018 ).

The difference between a diagnosis-based and process-based approach may be illustrated by an example. The network in Figure 1 represents a client who plausibly fits the diagnostic profile of major depressive disorder according to the DSM or ICD, given that they report such depressive symptoms as low mood, low motivation to engage in hobbies, and feelings of worthlessness and guilt. Nonetheless, assignment of a diagnosis would require a standard diagnostic interview and cannot be made based on the elements of Figure 1 alone. If, however, this client was given a diagnosis of “major depressive disorder” based on a formal assessment, choices for evidence-based treatment would include behavioral activation, cognitive behavioral therapy, and interpersonal therapy ( Gloaguen et al., 1998 ; Cuijpers et al., 2007 , 2011 ), and clinicians could choose among these options. However, as depicted in Figure 1 , the core belief that “I am a bad person” appears to be a primary driver of the other aspects of the client’s presentation. Thus, a clinician might decide to focus on cognitive intervention strategies as a first step, predicting that it would result in downstream effects of improving other problems.

Application of process-based therapy and current case illustration

In PBT, the treatment goal is to move clients toward adaptive growth relying on variation, selection, and retention along the EEMM dimensions and levels in a given context. In the closet analogy, this is equivalent to having the client try on different items of clothing ( variation ), identify which work for which occasions ( selection in context ; e.g., flip-flops for the beach and coat for winter hiking), and keep wearing appropriate clothing in specific contexts ( retention in context ). For the client in Figure 1 , this may mean trying different cognitive strategies (e.g., restructuring from cognitive therapy, defusion from acceptance, and commitment therapy [ACT]) in different contexts (e.g., when feeling sad vs. feeling neutral) to cope with the core belief, and to be able to deploy those strategies matched to context the next time the core belief shows up.

If PBT becomes the vehicle for evidence-based intervention to shift from a focus on protocols for disorders to a focus on the personalized needs of particular people, networks mapping clinically relevant processes for each person (see Figure 2 for an example) will become commonplace as a way of organizing the idiographic deployment of evidence-based treatment components or kernels (e.g., interpersonal effectiveness skills from DBT and interoceptive exposure from CBT). This is not an entirely new vision since it echoes the focus on functional analysis in the early days of behavior therapy, wherein general principles were applied to individual presentations, such that even if reinforcement was targeted, the form it took could be vastly different (e.g., attention vs. candy vs. money; Barlow and Hersen, 1973 ; Kanfer and Grimm, 1977 ).

www.frontiersin.org

Figure 2. Preliminary case conceptualization for Amy. EEMM dimensions represented by each node are bolded. Size of the arrowheads indicates hypothesized strength of the relationship (bigger arrowheads = stronger correlation), and opacity reflects direction of the relationship (opaque = positive/excitatory, transparent = negative/inhibitory). Right-angled rectangles reflect manipulable variables and rounded rectangles indicate immutable moderators (e.g., historical events).

There are major differences, however. The set of replicated nomothetic processes of change is now vastly larger than the behavioral learning principles (e.g., positive reinforcement in operant conditioning) that were then emphasized, which means there are many more tools and processes from which clinicians can choose on aggregate ( Hayes et al., 2022 ). However, an idiographic lens entails precision in how processes are targeted, with the understanding that not every process is relevant to every client. For instance, distress tolerance might be important for someone with high emotional reactivity and sensitivity, whereas social skills training may be more important for someone who lacks interpersonal skills. Furthermore, unlike direct nonverbal contingencies alone, contemporary biopsychosocial processes of change are understood to be dynamic and progressive, and thus to require such analytic tools as dynamical systems analysis—wherein the state of a datapoint is assumed to be time-varying but predictable based on certain inputs (e.g., past behavior predicting future behavior)—to construct adequate functional analyses ( Curtiss et al., 2021 ; Hofmann et al., 2021 ; Roefs et al., 2022 ), not merely classical single case designs ( Hayes et al., 1999 ).

While the possible number of relevant processes of change is very large, evolutionary science has emerged as a parsimonious framework within which to help organize comprehensive analyses of client needs and goals across relevant dimensions and levels of biopsychosocial processes ( Hayes et al., 2020a , b ). Importantly, measurement tools and statistical methods are now available to help gradually turn this new approach to functional analysis into a largely empirical rather than a largely conceptual tool (e.g., Group Iterative Multiple Model Estimation [GIMME], Process-Based Assessment Tool [PBAT]; Gates and Molenaar, 2012 ; Ciarrochi et al., 2022 ; Sanford et al., 2022 ).

Clearly, from our vantage point, the potential of PBT is vast. We anticipate that PBT can fundamentally alter how we conceptualize mental wellbeing and design psychological treatments, leading to the development of interventions that can more effectively and efficiently meet the needs entailed in infinite human complexity. Yet, more research and clinical testing are needed to clarify and refine its application across a range of contexts. The present case illustration represents an initial step toward this effort of explicating the application of PBT principles, to provide a clinical face to the core theoretical features of the PBT research program.

Case illustration

Client description.

To illustrate how PBT may be applied with a real-life example, we describe the course of treatment for an actual recent client, Amy, who was treated using a PBT approach to CBT. Some content details have been changed to anonymize Amy, but concepts remain functionally similar. Amy (she/her) was a cisgender White woman in her late 30 s working full-time at a university administrative job while managing a consultation business part-time at the point of study enrollment.

Based on results from the Mini International Neuropsychiatric Interview 7.0 ( Sheehan et al., 1998 ), a semi-structured clinical interview for DSM-5 diagnoses, Amy was assigned a primary diagnosis of generalized anxiety disorder. The specific problems Amy reported were “incessant checking” of financial and email accounts, avoidance of going outside due to compulsion to report public hazards to local authorities, indecision around her own career path, and rigid adherence to standards around being “responsible.” Amy’s initial treatment goals were to clarify her values, increase physical activity, develop a plan for leaving her full-time job to focus on her consulting business, be more present in interpersonal interactions, and maintain healthy interpersonal boundaries with loved ones.

Case conceptualization via network modeling

In the first two sessions of treatment, the therapist and Amy developed a preliminary network model based on her self-reported problems via clinical interview and discussion (see Figure 2 ). Each node (events represented in rectangles) or edge (relationships represented by arrows) were agreed to by Amy before being added to the network. Right-angled rectangles reflect manipulable variables and rounded rectangles indicate immutable moderators (e.g., historical events). Changeable nodes (rectangles) were defined functionally rather than topographically. For example, “proactively solving problems” covered Amy’s reporting of public hazards to authorities as well as other forms of excessive problem solving, such as making contingency plans for anticipated negative outcomes.

The selection of which nodes and edges were emphasized and retained were determined by functional analyses rooted in Amy’s primary presenting concerns: excessive checking and constant pressure to act responsibly or thoughtfully. For example, starting with excessive checking (identified behavior), the therapist and Amy explored potential antecedents and consequences contributing to or maintaining the unhelpful behavior. Together, they clarified that the pressure to act responsibly directly contributed to Amy’s excessive checking and that checking was reinforced by a sense of peace and reductions in worry about being seen as irresponsible and pressure to be responsible in the short term. Similarly, Amy hypothesized that the constant pressure she experienced to be responsible might be linked to a core belief that she needs to prove her worth and worries about being seen by others as irresponsible.

Further functional analyses were used to clarify how newly identified nodes were linked to the existing network or branched off to new areas. For instance, the self-label of “selfish” was absent at the inception of the network; it was only added after several functional analytic explorations and Socratic questioning wherein Amy realized that she had been carrying the self-label of “selfish” and the label was, in turn, driving other nodes like worry about external judgment and the core belief of needing to prove her worthiness. Typically, in the first few follow-up functional analyses, we would find that newly identified nodes linked back to existing ones. As shown in Figure 2 , for example, the “selfish” self-label was hypothesized to be associated with five other nodes.

As expected, however, the further out we went from the core problem, the fewer the number of edges connected back to the network. Thus, in terms of deciding how much to expand the network, we used the recommendation outlined in the PBT guide, Learning PBT : “as complex as necessary and as simple as possible” (p. 20, Rubel et al., 2018 ). In other words, we considered relevance to the network and presenting concern to give us a sufficiently complex understanding of Amy’s struggles to inform treatment planning, while letting go of other variables that may have been related to Amy’s struggles but did not incrementally contribute to treatment planning.

As an example, an early iteration of Amy’s network included a history of learning difficulties that she believed contributed to her attentional bias toward things going wrong, but through discussion, it seemed that the more pertinent contributor was her upbringing in a volatile household. Moreover, learning difficulties did not directly relate to other parts of her network or shape treatment planning beyond that explained by existing nodes (e.g., critical parents), thus, it was excluded from the first draft of Amy’s network.

Once the network was completed, self-amplifying subnetworks were identified to clarify potential treatment targets. As can be seen in Figure 2 , Amy’s preliminary network contains several self-amplifying loops or subnetworks that are self-maintained, one of which is illustrated in Figure 3 . In this self-amplifying loop, occurrence of the self-concept of “selfish” leads Amy to worry that others will perceive her as irresponsible or selfish, which then leads her to focus on problems in the physical or social environment in a hyper-vigilant way. This attentional bias, in turn, leads her to be more likely to view herself as “selfish” and to worry even more about external judgment. Because this part of the network is self-amplifying, no external input is needed to maintain the self-criticism, worry, and attentional bias cycle, making it especially critical to disrupt it during intervention.

www.frontiersin.org

Figure 3. Self-amplifying loop from Amy’s broader case conceptualization. EEMM dimensions represented by each node are bolded. Size of the arrowheads indicates hypothesized strength of the relationship (bigger arrowheads = stronger correlation).

A different example of a subnetwork is shown in Figure 4 . In this case, inhibitory arrows contribute to the self-perpetuating pattern. A moderator from Amy’s past (“parents were critical”) continues to drive the worry of being viewed as selfish and the core belief that she needs to prove herself worthy, despite the inhibitory influence of checking behavior. For instance, worry that others will see her as selfish brings up fear of making an “irresponsible” decision, which leads Amy to repeatedly check online accounts and to research decisions. These compulsive behaviors are negatively reinforced in the short term because they decrease her worry of being viewed as selfish and fear of making a poor decision. Without the sociocultural moderator of critical family members, this should dampen the self-perpetuating cycle, but Amy’s history keeps her worry and core belief active (note the relatively bigger arrowheads reflecting stronger hypothesized influence), such that the loop persists despite short-term reduction in worry and fear. Furthermore, the subnetwork functions on a short timescale (daily), such that a similar subnetwork with a monthly timescale may actually show that checking increases worry.

www.frontiersin.org

Figure 4. Subnetwork with inhibitory effects. EEMM dimensions represented by each node are bolded. Size of the arrowheads indicates hypothesized strength of the relationship (bigger arrowheads = stronger correlation), and opacity reflects direction of the relationship (opaque = positive/excitatory, transparent = negative/inhibitory). Right-angled rectangles reflect manipulable variables and rounded rectangles indicate immutable moderators (e.g., historical events).

Of note, a key node in Amy’s network is worry about being perceived as irresponsible or selfish, which coheres with the primary assigned diagnosis of GAD, potentially raising questions about the incremental utility of a network case conceptualization. Although a PBT approach may ultimately identify the same broad treatment target as a DSM diagnosis, which is “worry” in this case, the distinct feature of PBT is that it also identifies the downstream and upstream variables tied to worry (e.g., attentional bias for things going wrong, “selfish” label, pressure to be responsible, excessive checking, problem solving; see Figure 2 ) that may elude a GAD diagnosis alone. The practical implication of this is that the PBT approach would provide more personalized treatment targets for Amy (e.g., acceptance of perceived pressure to be responsible and mindfulness training to increase attentional flexibility) rather than recommend general evidence-based approaches for worry like worry time or cognitive restructuring.

Assessment of treatment progress

The network is a dynamic, transitory system to guide case conceptualization and treatment progress ( Fried et al., 2017 ; Curtiss et al., 2021 ; Roefs et al., 2022 ). Its purpose is to capture the complexity of the client’s problems and to serve as a way to identify causal influences, identify treatment targets, and monitor treatment progress. In a PBT approach, the network is viewed as constantly changing and thus needs to be re-examined on a regular basis, especially during therapy.

In order to characterize the network of processes of change empirically, over the course of treatment, Amy completed personalized ecological momentary assessment (EMA) items four times a day based on her case conceptualization (see Table 1 ). EMA items were rated using a visual analog scale from 1 to 100. The wording and frequency of items are presented in Table 1 .

www.frontiersin.org

Table 1. Personalized ecological momentary assessment items over the course of treatment.

Daily self-report items

Assessment initially included behavioral goals (duration) and key nodes in Amy’s network determined in the first two sessions of treatment. As Amy began to practice new skills and add adaptive nodes to her existing network, we replaced the original prompts with items describing her new adaptive network and assessing progress vis-à-vis her goals. All items were personalized to Amy’s presentation and developed collaboratively with her input. That is, items were only added to the daily assessment if Amy agreed that they would be relevant to her wellbeing. Table 1 lists these daily self-report items from baseline to the end of treatment.

Network analysis

Amy’s network data were analyzed using the Group Iterative Multiple Model Estimation (GIMME; Gates and Molenaar, 2012 ) package in R version 4.2.0 ( R Core Team, 2022 ). GIMME is an idiographic algorithm applied in a structural equation modeling (SEM) and Vector Autoregressive (VAR) framework that identifies how variables of interest relate to each other and evaluates the strength of the relationship among variables. GIMME accounts for longitudinal data and corresponding autoregressive effects by estimating the unified SEM ( Lane et al., 2021 ), which permits evaluation of contemporaneous and temporally lagged relations among variables of interest simultaneously. In addition, contemporaneous directionality is indicated when X at time t explains more variance in Y at time t than Y at time t does in X at time t , after addressing other variables in the model, including autoregressive effects. Contemporaneous directionality is not equivalent to causality given lack of experimental control, but it can be generally predictive of temporal relationships in smaller temporal windows than those used to collect the EMA data.

In GIMME, individual-level models are first estimated independent of any group-level data, and group-level (and, if relevant, subgroup level) models are subsequently generated based on individual-level models, retaining edges only if they apply to the majority of individuals in the sample. In the present case, because there was only one participant, only an individual-level model was generated, and the group-level step produced the exact same results as the individual-level model given an N of 1. The subsequent model fitting for the individual-level model is resolved when there is an excellent model fit based on two of four model fit indices: root mean square error of approximation (RMSEA) < 0.05, standardized root mean square residual (SRMR) < 0.05, non-normed fit index (NNFI) > 0.96, and comparative fit index (CFI) > 0.95 ( Bentler and Bonett, 1980 ; Bentler, 1990 ; Steiger, 1990 ; Hu and Bentler, 1999 ; Brown, 2015 ). Model estimation and missing data were handled using full information maximum likelihood. More details on GIMME procedures can be found in Gates and Molenaar (2012) .

Treatment plan

In the third session, the therapist reviewed the conceptual network model with Amy ( Figure 2 ), confirming with her that the model was accurate to her experience. In the third session, the therapist reviewed the conceptual network model with Amy ( Figure 2 ), confirming with her that the model fit with her experience and with her own conceptualization of her struggles. This is in the spirit of the idiographic PBT approach to assessment as opposed to a top-down “expert clinician” approach. Based on this understanding of Amy’s struggles, the therapist and Amy collaboratively developed a treatment plan. Based on Amy’s goals and network, they agreed that treatment would start with targeting inflexibility around personal standards (e.g., needing to be responsible or worthy) and attentional control (e.g., being more present).

Amy’s rigidity around personal expectations manifested in significant time spent on problem solving, checking online accounts, and researching prior to decision making in response to worry and her core belief. For example, her need to be responsible or perceived as responsible led to her spending hours comparing household products before purchasing one. Thus, we hypothesized that if Amy was able to hold personal standards more lightly, she would respond to them in more values-consistent and wellness-enhancing ways.

Amy also had difficulty regulating her attention, primarily focusing on negative aspects of situations and people—partly due to her chaotic childhood in which this hypervigilance was adaptive. As an adult, however, the hypervigilance reinforced the self-concept that she was “selfish,” led to worry about negative evaluation, and motivated excessive preemptive problem solving. We hypothesized that if Amy learned to shift attention intentionally, she would still retain the ability to be vigilant, when necessary, but also be present and open to other sources of data about herself and those around her (e.g., she is kind, others find her charming) when not exclusively attuned to negative concepts.

Treatment description

At the end of the first three sessions of collaborative case conceptualization and treatment planning, the therapist provided psychoeducation on how standards govern behavior when they are held rigidly and asked Amy to think of examples where standards may be driving her behavior (functional analysis from CBT; e.g., Barlow et al., 2017 ). Amy noted that the expectation that she “needs to respond to people as quickly as possible” was a motivator of her incessant checking behavior. The therapist then assigned homework to Amy to identify 5-10 standards she follows and ways in which those standards influence her behaviors to increase self-awareness through self-monitoring.

In session 4, Amy reported that she had discovered many standards that were influencing her behavior and, with this awareness, was able to respond to them more flexibly using cognitive defusion from ACT. For instance, Amy had gone on a vacation in between sessions and noticed the standard, “I need to make the most of my vacation,” which would have typically led her to pack her schedule with back-to-back activities. Instead, once she noticed this standard, she intentionally chose to enjoy a slow breakfast in the morning and only started exploring the city in the late morning, demonstrating healthy variation in responding (i.e., potentially useful responses outside her existing repertoire).

To facilitate selection of adaptive responding, the therapist asked Amy to track the consequences of this new behavior. For instance, Amy noted that she enjoyed her day more and relaxing her standards even gave her the opportunity to try out unplanned activities, which satisfied her desire for adventure. Directing Amy’s attention to these outcomes was important for helping Amy determine if her new responses were adaptive (and thus should be selected for retention in her repertoire) or maladaptive (and thus continued variation was needed). In other words, variation alone is inadequate. Amy also needed to evaluate the utility of any new responding to eventually shape a more salubrious set of responses.

In addition, Amy said that tracking her behaviors had been helpful for supporting desired behavior change. To capitalize on momentum toward positive behavior change and to reinforce flexible responding, the therapist asked Amy to practice doing behaviors that served her wellbeing for homework. Note that by defining the behavioral task functionally (i.e., “serve wellbeing”), the therapist was giving Amy room to continue varying forms of enhancing wellbeing (e.g., waking up late, going to the gym, and connecting with old friends) and to ultimately select those that were most effective in meeting her needs.

In the next three sessions ( Worden et al., 2017 ; Marker and Norton, 2018 ; Tolin, 2020 ), Amy reported that identifying and responding flexibly to standards had been “empowering” for her. She provided examples of explicitly communicating her needs, asking for help from others, driving instead of walking when it was cold, saying no to burdensome requests, and delaying responding to emails. Amy noted that these behaviors were consistent with her values (she had previously done values clarification work through a leadership training) and was able to generalize flexible responding to rules to various life domains. Moreover, Amy observed that the feeling of empowerment she derived from flexible responding was “self-reinforcing.” The reinforcing function of the feeling of empowerment, along with other new behaviors, was added to Amy’s network conceptualization (see Figure 5 ). The eventual objective was to transition from Amy’s stable maladaptive network to a sustainable adaptive network.

www.frontiersin.org

Figure 5. Subnetwork with adaptive nodes added after start of treatment. EEMM dimensions represented by each node are bolded. Size of the arrowheads indicates hypothesized strength of the relationship (bigger arrowheads = stronger correlation), and opacity reflects direction of the relationship (opaque = positive/excitatory, transparent = negative/inhibitory). Right-angled rectangles reflect manipulable variables and rounded rectangles indicate immutable moderators (e.g., historical events). Reinforcing valence of “feeling empowered” is indicated by double-headed excitatory arrows with “responding flexibly to standards and expectations,” “setting and adhering to interpersonal boundaries,” “building connection with others,” and “engaging in self-care activities.”

During this time, Amy made two significant life decisions. The first was to resign from her full-time administrative job to focus on her consulting business and the second was to undergo an elective surgery to improve her physical health, which generated anticipatory excitement and indecisiveness, eliciting the familiar pressure to act responsibly or thoughtfully. These decisions resulted in re-activation of her original network (e.g., increasing worry that others will judge her decisions negatively), though Amy clarified that the decisions was consistent with her values and could conceptualize them as forms of self-care, engaging with her newer “adaptive” subnetwork (see Figure 5 ).

At the end of session 7, the therapist and Amy reviewed personalized items to track via EMA, which led to a revision of the EMA survey (see Table 1 ). The revisions clarified Amy’s current treatment goals and added progress items to monitor progress toward her updated goals. The reason for the EMA review was that Amy had already achieved her early treatment goals of clarifying her values, increasing physical activity, leaving her full-time job, being more present in interpersonal interactions, and maintaining healthy interpersonal boundaries with loved ones.

Starting in session 8, treatment became more focused on retaining newly selected behaviors and further enhancing wellbeing, after Amy indicated that she would like to continue treatment to work on practicing healthy detachment from thoughts and feelings, structuring her life in a more balanced way (e.g., having hobbies outside of work), and being more intentional with her actions. At this time, Amy reported continued reduction in problematic behavior (e.g., reporting public hazards once a week vs. multiple times a week) and an increase in helpful behaviors, such as building interpersonal connections, being more present, and practicing detachment from her expectations and emotions—which, in turn, facilitated valued action.

At the same time, Amy experienced novel stressors related to her significant decisions: managing a business on which she was now primarily financially dependent and decreased access to values-based activities (e.g., socializing with friends, attending public events, and exercise) due to recovery from surgery. For example, she worried about finding health insurance, filing taxes as a business owner, and maintaining financial stability. Thus, although Amy had retained selected skills, her context shifted, providing a useful test for the resilience of Amy’s adaptive network in Figure 5 : would she revert to maladaptive responses (e.g., compulsive checking) or be able to engage in new strategies she had been practicing?

Amy reported improved ability to handle some of these new stressors due to increased “trust in [herself]” to make healthy decisions and evaluating the effectiveness of those decisions with respect to her values. However, she also observed that, in other instances, she was “still trying to prove herself by overcommitting,” which was related to her core belief that she needed to prove her self-worth to others. Treatment was thus spent on reinforcing referencing values rather than standards when making choices in the presence of distress and reflecting on how well she was able to accomplish this since the last session.

In session 12, Amy brought up the issue of struggling to keep up with her values, and it became apparent that Amy had been trying to maximize her values to the extent that doing so felt overwhelming. In addition, she was so concerned with planning her “best life” that she was having difficulty being present when engaging in valued activities. These problems, while different in form, were functionally similar to Amy’s original struggles of attentional rigidity and compulsive problem solving, indicating that Amy had indeed reverted back to parts of her old network. While Amy reported that she was able to respond flexibly to standards and preset boundaries, she found attentional flexibility more challenging. Accordingly, the therapist and Amy reviewed attentional control and mindfulness skills and being discerning about which values to enact.

The final three sessions 16–18 consisted of reflecting on helpful strategies, the contexts in which they worked, ways to generalize and evaluate effectiveness of strategies, progress made, and areas to continue to strengthen. In particular, the sessions focused on the sustainability of changes she was implementing.

Treatment outcomes

Ecological momentary assessment items included Amy’s initial behavioral goals of decreasing use of the email app on her phone and increasing physical activities and, in the latter part of treatment, progress toward new goals. Figure 6 shows changes over time in Amy’s initial behavioral goals, which appears to show greater variability in physical activity over time (with less activity in March due to recovery from surgery) and a steady increase in use of her email app. These behavioral outcomes along would suggest little response to treatment, though it is possible their function changed over time given Amy’s significant contextual shift (e.g., resigning from job to run coaching business full-time). For instance, Amy reported that checking emails became more about managing the transition from part-time to full-time consulting rather than to alleviate worry.

www.frontiersin.org

Figure 6. Minutes spent using mail app and engaging in physical activity over the course of treatment. The dashed vertical line indicates the start of treatment. Shaded area shows 95% confidence intervals for best-fitting lines.

We also tracked Amy’s degree of progress toward goals and trust in herself (e.g., to make healthy decisions and engage in valued action) daily (see Figure 7 ). Even though Amy rated herself highly on progress toward goals and trust in self (scores were around 90 out of 100) at the beginning of assessment, there was more fluctuation in the first 2 months (February to April) relative to the latter 2 months of tracking (May to July), suggesting that these indices of progress became more consistent over time.

www.frontiersin.org

Figure 7. Amy’s scores for self-rated progress toward goals and degree of trust in herself from mid- to posttreatment.

Group iterative multiple model estimation networks

We used the GIMME algorithm to empirically map parts of Amy’s network during the start and end of treatment (97 observations over 36 days and 233 observations over 169 days, respectively; note that data were collapsed over weeks and do not represent any specific timepoint). Due to participant burden of responding to multiple items multiple times a day, we modeled approximately five nodes of the network for each period. To evaluate consistency between our hypothesized network and the data-driven network, we inspected presence, direction, and strength of the relationships between nodes, noting any significant discrepancies (e.g., direction of arrow was opposite to prediction). The plan was to clarify these discrepancies with the client and adjust the treatment plan accordingly, before continuing empirical testing to see if our revised hypotheses led to more adaptive responding.

The network on the left of Figure 8 shows that, at the start of treatment, Amy’s hyper-vigilance for things going wrong was associated with feeling less peaceful and more attentional bias at the next measurement occasion. In turn, feeling at peace was related to less perceived pressure to act responsibly or thoughtfully. In other words, the hyper-vigilance had a suppressive influence on what could have been a buffer for feeling pressure to be responsible, which was itself linked to more problem solving. Problem solving was associated with greater attentional bias toward problems in her environment, completing a cyclical pattern of looking out for problems and feeling an obligation to immediately resolve them.

www.frontiersin.org

Figure 8. Group Iterative Multiple Model Estimation (GIMME)-derived network showing contemporaneous and lagged relationships among EMA items completed by Amy in the first month of treatment on the left, compared to our hypothesized network on the right. Solid lines, contemporaneous; dashed lines, lagged; solid arrowhead, excitatory or positive relationship; blank arrowhead, inhibitory or negative relationship. Size of arrowheads corresponds to strength of relationship estimated by GIMME analyses. Beta estimates are presented in Supplementary Table S1 in Supplementary material .

Our hypothesized network on the right of Figure 8 indicates several discrepancies compared to the empirically formulated network. For example, we had missed the suppressive influence of feeling at peace on the pressure to be responsible and misidentified the direction of the relationship between hypervigilance and problem solving. In terms of treatment planning, this means that we could have done more to practice strategies to bolster Amy’s feelings of peacefulness or to address the pressure to be responsible. In this specific instance, the intervention plan of focusing on attentional regulation and flexibility with respect to standards ended up targeting overlapping pathways (e.g., attentional regulation may have helped Amy to feel more at peace, which led to less problem solving through less pressure to be responsible), which may explain why treatment was still effective. However, our hypothesized processes of change were inaccurate and understanding how change actually occurred has implications for which strategies would be most helpful for targeting potential resurgence of maladaptive behaviors in the future.

As the original nodes became less relevant to Amy’s treatment given that she was building new skills, we began tracking new processes in the latter part of treatment to assess whether Amy was able to maintain a new adaptive network in the presence of stressors. Using GIMME, we found that responding flexibly to standards and expectations was associated with more awareness of current feelings, self-care, and connection building, demonstrating validity that cognitive flexibility was an important skill for Amy (see Figure 9 ). Furthermore, it resulted in more flexible responding at the next measurement occasion, suggested it was self-sustaining, similar to awareness of feelings. The lagged self-recursive relations suggest that the more Amy practiced these skills, the more she was able to access them at subsequent occasions.

www.frontiersin.org

Figure 9. Group Iterative Multiple Model Estimation-derived network showing contemporaneous and lagged relationships among EMA items completed by Amy in the final few weeks of treatment on the left, compared to our hypothesized network on the right. Solid lines, contemporaneous; dashed lines, lagged; solid arrowhead, excitatory or positive relationship. Size of arrowheads corresponds to strength of relationship estimated by GIMME analyses. Beta estimates are presented in Supplementary Table S2 in Supplementary material .

Building connection and being present with others not only led to more connection building at the next timepoint but also was associated with an increase in feeling empowered. Feeling empowered also resulted in more of the same at the next assessment, corroborating Amy’s self-report that empowerment was self-reinforcing. Feeling empowered was itself linked to more cognitive flexibility and self-care. By looping back to cognitive flexibility, a three-node self-amplifying subnetwork resulted (cognitive flexibility → building connection → empowerment).

A second self-amplifying networks was identified empirically by GIMME through the feeling of empowerment node because self-care was related to more awareness of current feelings and, at the next timepoint, building connection with others and then back to empowerment.

All the relationships in these networks were excitatory and every node was endogenous (had an arrow feeding into it). Taken as a whole, the entire network and these two self-amplifying subnetworks in particular, seem likely to be stable and self-perpetuating. Clinically, we observed that Amy continued to access skills of cognitive defusion and building connection in the presence of significant stressors, which supports that possibility.

In comparison to the empirical network, the hypothesized network missed that cognitive flexibility and self-care might be positively linked to building connection with others and that self-care was more likely to drive awareness of current feelings that the other way around (see Figure 9 ). While this discrepancy would not significantly change our treatment plan, we might place less emphasis on practicing mindfulness of feelings as its own end if Amy did not find this to be a helpful skill. In this case, Amy reported that it was helpful in itself, even though it did not influence other nodes as we had hypothesized.

Lessons learned

Burden of repeated tracking on client.

Although Amy was initially compliant with completing EMA surveys four times daily, she reported that she found it stressful and difficult to keep up with the surveys on several occasions, resulting in more missing observations toward the end of treatment. This was the primary reason we chose to minimize the number of items administered in each survey. Ideally, we would track every node in Amy’s networks, but this was not pragmatically feasible.

The potential burden of tracking for some clients warrants judicious planning, to the extent possible when working with complex dynamic systems, of variables that can be consistently assessed over the course of treatment. This set of variables should include problematic and desired behaviors and progress toward established treatment goals to capture a comprehensive picture of client functioning and wellbeing. Furthermore, clinicians should generally strive eliminate redundancy and select maximally orthogonal items to explain as much variance with as few items as possible. This may require some form of pilot testing in the first couple weeks of treatment to empirically determine which items to retain.

However, as a caveat, by definition, a dynamic system changes over time, and our preliminary best guesses are necessarily based on a snapshot of the client at intake. Thus, even with careful planning, clinicians may still need to adjust assessment based on client’s evolving needs and goals to meet the constant objective of improving their wellbeing and reducing suffering. Furthermore, given empirical considerations, clinicians also need to be aware of the potential ramifications of administering fewer items, especially if classical psychometric theory is a primary guide. Psychometric validity may be compromised when as few as one item is used to capture a multifaceted psychological construct, increasing measurement error as traditionally viewed within psychometrics ( Piccirillo et al., 2019 ; Bringmann et al., 2022 ). Possible ways to circumvent these issues include incorporating passively collected data (e.g., from wearables and smartphones), reducing number of assessment timepoints, and using planned missing data designs and imputation methods for multivariate time series data ( Piccirillo et al., 2019 ; Bringmann et al., 2022 )—though implementation of these strategies must be theoretically and methodologically defensible, especially since the idiographic basis of PBT challenges features of traditional psychometrics ( Ciarrochi et al., 2022 ).

Duration of assessment

Group Iterative Multiple Model Estimation requires a minimum of 60 datapoints (ideally 100) to reliably estimate a network for a given individual ( Lane et al., 2019 ). Considering our previous point about participant burden, one might recognize a tension between getting data quickly to empirically verify hypotheses as soon as possible and minimizing the number of times a client has to complete a daily EMA survey. For instance, we could collect the necessary data for GIMME analyses in approximately 2 weeks with four daily assessments or take a month with two daily assessments. In addition, aside from addressing pragmatic concerns, using varying timescales impacts the construct validity of variables being measured as viewed in a psychometric context ( Bringmann et al., 2022 ). For example, assessing rapidly shifting constructs less frequently (or vice versa) increases measurement error as traditionally conceived. Thus, clinicians must bear in mind the hypothesized rate of change of variables of interest when determining the delivery schedule of EMA items. While Bayesian methods may eventually permit fewer observations for analysis due to initial consideration of clinically driven starting estimates (as opposed to starting from zero information; Burger et al., 2021 ), most currently available statistical methods still require significant client input via intensive longitudinal assessment.

Changing relevance and function of personalized items

Amy was very involved in the case conceptualization and assessment process, providing input into which items she hypothesized would be helpful to track and were most relevant to her goals. As Amy expanded her network over the course of treatment—adding adaptive nodes and decreasing engagement in maladaptive nodes—the most relevant items changed accordingly. For example, Amy initially tracked how much she felt pressure to be responsible or thoughtful, which contributed to compulsive problem solving and checking, but later was more interested in tracking the extent to which she acted in ways that served her wellbeing as her compulsive behaviors decreased over time and self-care activities gradually increased.

The decision to drop items with low frequency was clinical and pragmatic. First, the therapist and Amy decided that it would be more helpful to focus on behaviors that Amy wanted to retain over time from a strengths-based perspective. Second, Amy found completing surveys four times daily for more than five to eight items burdensome, so we needed to distill the EMA items down to the most relevant and essential variables. However, the change in variables measured presented a research problem: how do we measure progress using different metrics at pre- and posttreatment? Our solution to this quandary was to introduce progress items (see bottom row of Table 1 ) that were designed to capture overall progress with respect to Amy’s overarching treatment goals. These goals were important in that the closer Amy was to accomplishing these goals, the more she was satisfied with the direction of her life.

Failure of topographical behavioral variables to capture adaptive change

Amy initially presented as extremely high-functioning and had already been reporting high frequency of desired behavior (i.e., exercise), which made seeing a further increase in physical activity improbable. In addition, the function of her use of the email app on her smartphone changed over the course of treatment, such that its consistent frequency did not reflect a constant state. Specifically, Amy quit her full-time job during treatment and dedicated more time to building her consulting business. Thus, the initial function of checking emails to reduce anxiety about being perceived as irresponsible or selfish shifted to approaching her value of being financially stable and growing her business. These interpretations are supported by Amy’s self-report that she was no longer immediately responding to emails and more willing to wait until it was a convenient time to do so. In this case, even though the variable remained the same, its meaning and relevance to Amy’s wellbeing had changed. Said in another way, this case revealed once again that topographically defined behavioral goals are not necessarily the same as functionally defined outcomes. The topography-function discrepancy in assessment is one reason to focus on processes of change. In this case the therapist and Amy also introduced variables that were a shorthand for positive change Amy had made in treatment.

The importance of empirical case networks

Knowing that treatment works is not the same as knowing how treatment works. It would have been reasonable to assume because our clients improved in expected ways, that our treatment plan accurately represented core struggles and processes of change. GIMME, used as an empirical case conceptualization tool, showed otherwise. In the present case, this discrepancy turned out to be largely inconsequential—given that our treatment plan targeted pathways that overlapped with those indicated by the empirically derived network—but that should not be assumed. Understanding how treatment works for specific individuals is important once a process-focus is adopted and, thus, the larger lesson of the present case is that conceptual network analysis should not be relied on as the sole evidence of how processes of change apply to a case. Empirical methods need to be developed and used in conjunction with clinical judgment ( Burger et al., 2021 ).

With GIMME, we were able to clarify the processes of change involved in Amy’s response to treatment by checking parts of our hypothesized networks against empirically derived ones. Generally, while we found that had accurately hypothesized certain relationships, we sometimes overlooked relations or misidentified their directionality. The oversight, in Amy’s case, did not warrant an overhaul of our treatment plan, but it is entirely plausible that it could have. For example, if flexible responding to standards exerted no influence on any other node, then we would have needed to examine if Amy was properly practicing flexible responding to standards or if another cognitive strategy would have been more effective. At the same time, most analysts currently will hold empirically derived networks accountable to such traditional psychometric issues as measurement error, so clinicians will need to optimize their data collection setup for hypothesis testing beforehand. Moreover, once analyses have been completed, clinicians should verify empirical findings against clinical observations and client self-report to ensure they maintain a balanced and useful case conceptualization.

The inconsistency between conceptual and empirical networks points to a long-standing weakness of functional analysis, underscoring the need to take into account multiple sources of information ( Steiger, 1990 ). Functional analysis is still advocated in clinical psychology ( Haynes et al., 2011 ), but it is not commonplace because it has remained more of an art than a science. In applied behavior analysis, functional analysis grew substantially when it integrated empirical methods by using an alternating treatment design ( Barlow and Hayes, 1979 ) to identify idiosyncratic reinforcers for undesirable behavior ( Iwata et al., 1982 ). Unfortunately, if clients are even minimally verbal, that direct contingency approach plumets in its ability to reliably identify the functions of actions ( Belisle et al., 2017 ). Another functional analytic approach needs to be found that can accommodate the degree to which verbal/cognitive processes operate on and alter other processes. The present study suggests that the use of EMA data on processes of change analyzed empirically as an idiographic complex network may be that pathway forward. If broadly used, such an approach might provide data person by person on the use of precise clinical interventions linked to processes of change; in effect, building a constellation of cases that can help to inform future case conceptualization.

There will be multiple problems to overcome before that future is fully available, however. For example, when developing and interpreting client networks, clinicians need to clarify the timescale of the relationships among nodes. Hypothesized networks can readily specify variable temporal lags (e.g., healthy eating — > feeling energetic could take a week, whereas feeling energetic — > engaging in hobbies may occur over minutes) but existing network tools such as GIMME often assume that data are measured at equal intervals. Self-report items are difficult to assess on a granular level, but physiological data from wearables (e.g., heartrate variability) may be measured many times each second. In the present case, the empirically derived GIMME networks appeared to be less sensitive to temporally proximal relationships, such as the possible negative reinforcement of compulsive checking through reduction of anxiety. Thus, the generation of adequate idiographic biopsychosocial complex networks are far from turnkey at the present time.

Summary and recommendations

In this report, we provided a case illustration for using a process-based approach to case conceptualization, treatment planning, and treatment delivery to a client, Amy, in an outpatient setting. Generally, results from assessment data indicated that, despite initial high levels of functioning, Amy accumulated new skills targeting key nodes in her initial network that appeared to be resilient against external stressors and further improved her functioning. The specific steps of this case included:

(a) using a network comprised of interrelated variables rather than diagnostic labels and topographical symptoms to describe our client’s presenting problem;

(b) collaborating with the client on her case conceptualization, using her wording and input as much as possible;

(c) administering EMA items on a daily basis to collect intensive longitudinal data to evaluate treatment progress;

(d) designing treatment plan to target nodes that appeared to be contributing to other struggles;

(e) using idiographic statistical analysis to verify hypothesized networks;

(f) adjusting the treatment plan in response to empirical data and contextual shifts (should also be done in response to lack of progress, which did not occur in this case); and

(g) aiming to establish adaptive network and assessing sustainability and resilience of new network.

In some ways, because of the rigor, consideration, and expertise that went into our application of PBT, this case illustration may be considered a current “best-effort” example of how to implement PBT. We recognize that many clinicians may not have the time or bandwidth to monitor daily EMA data from clients, learn advanced statistical techniques, and generate multiple networks for each of the many clients on their caseload. Furthermore, we ourselves observed several aspects that we would do differently in the future, as noted in the Lessons Learned section above. Yet, our objective in providing this case illustration along with the lessons learned along the way was precisely to show that delivering PBT is an iterative process; no clinician will ever consistently deliver PBT “perfectly” given the complexity of our clients and fallibility of human clinicians.

Nonetheless, we believe that implementing principles and core pieces of a process-based approach is feasible. First, clinicians can create networks with their clients to better understand how their problems relate to and drive each other. This could supplement or replace the standard intake interview that most clinicians already do. Second, clinicians can design treatment plans based on the network, selecting among techniques they already have in their therapeutic arsenal. The difference is that the application of these techniques would be process-based, individually tailored, and hypothesis-driven—thereby more precise—rather than diagnosis-focused, similar to making a specific recommendation to eat more leafy greens over asking someone to eat more fruits and vegetables. Thirdly, clinicians who use routine outcome monitoring can use those existing items to test their hypotheses to the extent that the items are relevant and modify their approach accordingly. These changes would not require immense commitments and bring clinicians closer to a process-based approach. Finally, there is no reason that EMA and statistical tools cannot be automated in the form of apps, software, and clinical tools, making the applied task far easier.

Ultimately, through iterative learning, curiosity, cumulative skill acquisition, and the development of technical supports, clinicians will become better able to implement process-based principles with facility and build on existing methods to improve their delivery of idiographic, empirically grounded, and process-based care. It will gradually become easier to engage in intensive longitudinal data collection by automating passive collection of data, administration of self-report items, and complex analysis of these data as the field moves more in a PBT direction.

While PBT has the potential to reform the foundations of clinical practice, it is important to treat its value as a hypothesis that is as yet unproven. The change in direction it suggests is profound. Methods that have adopted a process-focused development strategy have been successful ( Hayes et al., 2022 ), and some supportive early randomized trials of PBT methods have appeared ( Ong et al., 2022 ), but that does not mean that adopting a PBT approach will necessarily lead to greater efficacy in psychological intervention writ large. Many case examples, clinical trials, and laboratory experiments with diverse populations will be needed to put empirical muscle on PBT’s theoretical skeleton. Thus, we offer the present case as a useful beginning example. We hope this paper will be the first of many to evaluate the efficacy and feasibility of a process-based approach. That is the only way to determine whether PBT can live up to its field-changing potential.

Ethics statement

The studies involving human participants were reviewed and approved by the Boston University Charles River Campus Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.

Author contributions

CO analyzed the data. SCH and SGH provided clinical supervision. All authors contributed to case conceptualization and manuscript write-up.

This study was funded in part by the Alexander von Humboldt Foundation.

Acknowledgments

We would like to thank Lisa Smith for providing additional supervision on this case.

Conflict of interest

SGH receives financial support from the Alexander von Humboldt Foundation and the James S. McDonnell Foundation 21st Century Science Initiative in Understanding Human Cognition – Special Initiative. He receives compensation for his work as editor from Springer Nature. He also receives royalties from various publishers.

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

Publisher’s note

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

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.1002849/full#supplementary-material

Barlow, D. H., and Hayes, S. C. (1979). Alternating treatments design: One strategy for comparing the effects of two treatments in a single subject. J. Appl. Behav. Anal. 12, 199–210. doi: 10.1901/jaba.1979.12-199

PubMed Abstract | CrossRef Full Text | Google Scholar

Barlow, D. H., and Hersen, M. (1973). Single-case experimental designs: Uses in applied clinical research. Arch. Gen. Psychiatry 29, 319–325. doi: 10.1001/archpsyc.1973.04200030017003

Barlow, D. H., Sauer-Zavala, S., Farchione, T. F., Latin, H. M., Ellard, K. K., Bullis, J. R., et al. (2017). Unified Protocol For Transdiagnostic Treatment Of Emotional Disorders: Workbook (Treatments That Work). New York, NY: Oxford University Press. doi: 10.1093/med-psych/9780190686017.001.0001

CrossRef Full Text | Google Scholar

Belisle, J., Stanley, C. R., and Dixon, M. R. (2017). The relationship between derived mutually entailed relations and the function of challenging behavior in children with autism: Comparing the PEAK-E-PA and the QABF. J. Context. Behav. Sci. 6, 298–307. doi: 10.1016/j.jcbs.2017.07.004

Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychol. Bull. 107, 238–246. doi: 10.1037/0033-2909.107.2.238

Bentler, P. M., and Bonett, D. G. (1980). Significance tests and goodness of fit in the analysis of covariance structures. Psychol. Bull. 88:588. doi: 10.1037/0033-2909.88.3.588

Bringmann, L. F., Albers, C., Bockting, C., Borsboom, D., Ceulemans, E., Cramer, A., et al. (2022). Psychopathological networks: Theory, methods and practice. Behav. Res. Ther. 149:104011. doi: 10.1016/j.brat.2021.104011

Brown, T. A. (2015). Confirmatory Factor Analysis For Applied Research , 2nd Edn. New York, NY: Guilford Press.

Google Scholar

Burger, J., Epskamp, S., van der Veen, D., Dablander, F., Schoevers, R., Fried, E., et al. (2021). A clinical PREMISE for personalized models: Towards a formal integration of case formulations and statistical networks. PsyArXiv [Preprint]. doi: 10.31234/osf.io/bdrs7

Butler, A. C., Chapman, J. E., Forman, E. M., and Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clin. Psychol. Rev. 26, 17–31. doi: 10.1016/j.cpr.2005.07.003

Chambless, D. L., and Hollon, S. D. (1998). Defining empirically supported therapies. J. Consult. Clin. Psychol. 66, 7–18. doi: 10.1037/0022-006X.66.1.7

Ciarrochi, J., Sahdra, B., Hofmann, S. G., and Hayes, S. C. (2022). Developing an item pool to assess processes of change in psychological interventions: The Process-Based Assessment Tool (PBAT). J. Context. Behav. Sci. 23, 200–213. doi: 10.1016/j.jcbs.2022.02.001

Covin, R., Ouimet, A. J., Seeds, P. M., and Dozois, D. J. (2008). A meta-analysis of CBT for pathological worry among clients with GAD. J. Anxiety Disord. 22, 108–116. doi: 10.1016/j.janxdis.2007.01.002

Cuijpers, P., Geraedts, A. S., van Oppen, P., Andersson, G., Markowitz, J. C., and van Straten, A. (2011). Interpersonal psychotherapy for depression: A meta-analysis. AJP 168, 581–592. doi: 10.1176/appi.ajp.2010.10101411

Cuijpers, P., van Straten, A., and Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clin. Psychol. Rev. 27, 318–326. doi: 10.1016/j.cpr.2006.11.001

Curtiss, J. E., Mischoulon, D., Fisher, L. B., Cusin, C., Fedor, S., Picard, R. W., et al. (2021). Rising early warning signals in affect associated with future changes in depression: A dynamical systems approach. Psychol. Med . [Epub ahead of print]. doi: 10.1017/S0033291721005183

Fisher, A. J., Bosley, H. G., Fernandez, K. C., Reeves, J. W., Soyster, P. D., Diamond, A. E., et al. (2019). Open trial of a personalized modular treatment for mood and anxiety. Behav. Res. Ther. 116, 69–79. doi: 10.1016/j.brat.2019.01.010

Fried, E. I., van Borkulo, C. D., Cramer, A. O. J., Boschloo, L., Schoevers, R. A., and Borsboom, D. (2017). Mental disorders as networks of problems: A review of recent insights. Soc. Psychiatry Psychiatr. Epidemiol. 52, 1–10. doi: 10.1007/s00127-016-1319-z

Gates, K. M., and Molenaar, P. C. M. (2012). Group search algorithm recovers effective connectivity maps for individuals in homogeneous and heterogeneous samples. NeuroImage 63, 310–319. doi: 10.1016/j.neuroimage.2012.06.026

Gloaguen, V., Cottraux, J., Cucherat, M., and Blackburn, I.-M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. J. Affect. Disord. 49, 59–72. doi: 10.1016/S0165-0327(97)00199-7

Hayes, S. C., Barlow, D. H., and Nelson-Gray, R. O. (1999). The Scientist Practitioner: Research And Accountability In The Age Of Managed Care. Needham Heights: Allyn & Bacon.

Hayes, S. C., Ciarrochi, J., Hofmann, S. G., Chin, F., and Sahdra, B. (2022). Evolving an idionomic approach to processes of change: Towards a unified personalized science of human improvement. Behav. Res. Ther. 156:104155. doi: 10.1016/j.brat.2022.104155

Hayes, S. C., and Follette, W. C. (1992). Can functional analysis provide a substitute for syndromal classification? Behav. Assess. 14, 345–365.

Hayes, S. C., Hofmann, S. G., and Ciarrochi, J. (2020a). A process-based approach to psychological diagnosis and treatment: The conceptual and treatment utility of an extended evolutionary meta model. Clin. Psychol. Rev. 82:101908. doi: 10.1016/j.cpr.2020.101908

Hayes, S. C., Hofmann, S. G., and Wilson, D. S. (2020b). Clinical psychology is an applied evolutionary science. Clin. Psychol. Rev. 81:101892. doi: 10.1016/j.cpr.2020.101892

Hayes, S. C., and Sanford, B. T. (2015). Modern psychotherapy as a multidimensional multilevel evolutionary process. Curr. Opin. Psychol. 2, 16–20. doi: 10.1016/j.copsyc.2015.01.009

Haynes, S. N., O’Brien, W., and Kaholokula, J. (2011). Behavioral Assessment And Case Formulation. Hoboken, NJ: John Wiley & Son.

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., and Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cogn. Ther. Res. 36, 427–440. doi: 10.1007/s10608-012-9476-1

Hofmann, S. G., and Hayes, S. C. (2019). The future of intervention science: Process-based therapy. Clin. Psychol. Sci. 7, 37–50. doi: 10.1177/2167702618772296

Hofmann, S. G., Hayes, S. C., and Lorscheid, D. N. (2021). Learning Process-Based Therapy: A Skills Training Manual For Targeting The Core Processes Of Psychological Change In Clinical Practice. Oakland, CA: New Harbinger.

Hu, L., and Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct. Equat. Model. Multidiscip. J. 6, 1–55. doi: 10.1080/10705519909540118

Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., and Richman, G. S. (1982). Toward a functional analysis of self-injury. Anal. Intervent. Dev. Disabil. 2, 3–20. doi: 10.1016/0270-4684(82)90003-9

Kanfer, F. H., and Grimm, L. G. (1977). Behavioral analysis: Selecting target behaviors in the interview. Behav. Modif. 1, 7–28. doi: 10.1177/014544557711002

Lane, S., Gates, K. M., Fisher, Z., Arizmendi, C., Molenaar, P., Hallquist, M., et al. (2021). gimme: Group Iterative Multiple Model Estimation [Internet]. Available online at: https://CRAN.R-project.org/package=gimme (accessed September 24, 2022).

Lane, S. T., Gates, K. M., Pike, H. K., Beltz, A. M., and Wright, A. G. C. (2019). Uncovering general, shared, and unique temporal patterns in ambulatory assessment data. Psychol. Methods 24, 54–69. doi: 10.1037/met0000192

Levinson, C. A., Hunt, R. A., Keshishian, A. C., Brown, M. L., Vanzhula, I., Christian, C., et al. (2021). Using individual networks to identify treatment targets for eating disorder treatment: A proof-of-concept study and initial data. J. Eat. Disord. 9:147. doi: 10.1186/s40337-021-00504-7

Linardon, J., Wade, T. D., de la Piedad Garcia, X., and Brennan, L. (2017). The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis. J. Consult. Clin. Psychol. 85, 1080–1094. doi: 10.1037/ccp0000245

Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., and Craske, M. G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria. Clin. Psychol. Rev. 42, 72–82. doi: 10.1016/j.cpr.2015.08.004

Marker, I., and Norton, P. J. (2018). The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis. Clin. Psychol. Rev. 62, 1–10. doi: 10.1016/j.cpr.2018.04.004

Mesoudi, A., Whiten, A., and Laland, K. N. (2006). Towards a unified science of cultural evolution. Behav. Brain Sci. 29, 329–347. doi: 10.1017/S0140525X06009083

Molenaar, P. C. M. (2004). A manifesto on psychology as idiographic science: Bringing the person back Into scientific psychology, this time forever. Measure. Interdiscip. Res. Perspect. 2, 201–218. doi: 10.1207/s15366359mea0204_1

Ong, C. W., Lee, E. B., Levin, M. E., and Twohig, M. P. (2022). Online process-based training for perfectionism: A randomized trial. Behav. Res. Ther. 156:104152. doi: 10.1016/j.brat.2022.104152

Paul, G. L. (1967). Strategy of outcome research in psychotherapy. J. Consult. Psychol. 31, 109–118. doi: 10.1037/h0024436

Piccirillo, M. L., Beck, E. D., and Rodebaugh, T. L. (2019). A clinician’s primer for idiographic research: Considerations and recommendations. Behav. Ther. 50, 938–951. doi: 10.1016/j.beth.2019.02.002

R Core Team (2022). R: A Language And Environment For Statistical Computing. Vienna: R Foundation for Statistical Computer.

Roefs, A., Fried, E. I., Kindt, M., Martijn, C., Elzinga, B., Evers, A. W. M., et al. (2022). A new science of mental disorders: Using personalised, transdiagnostic, dynamical systems to understand, model, diagnose and treat psychopathology. Behav. Res. Ther. 153:104096. doi: 10.1016/j.brat.2022.104096

Rubel, J. A., Fisher, A. J., Husen, K., and Lutz, W. (2018). Translating person-specific network models into personalized treatments: Development and demonstration of the dynamic assessment treatment algorithm for individual networks (data-in). Psychother. Psychosom. 87, 249–251. doi: 10.1159/000487769

Sanford, B. T., Ciarrochi, J., Hofmann, S. G., Chin, F., Gates, K. M., and Hayes, S. C. (2022). Toward empirical process-based case conceptualization: An idionomic network examination of the process-based assessment tool. J. Context. Behav. Sci. 25, 10–25. doi: 10.1016/j.jcbs.2022.05.006

Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 59, 22–33. doi: 10.1037/t18597-000

Springer, K. S., Levy, H. C., and Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clin. Psychol. Rev. 61, 1–8. doi: 10.1016/j.cpr.2018.03.002

Steiger, J. H. (1990). Structural model evaluation and modification: An interval estimation approach. Null 25, 173–180. doi: 10.1207/s15327906mbr2502_4

Tolin, D. F. (2020). Advances in the identification of empirically supported psychological treatments. Clin. Psychol. Sci. Pract. 27:e12356. doi: 10.1111/cpsp.12356

Worden, B. L., Bowe, W. M., and Tolin, D. F. (2017). An open trial of cognitive behavioral therapy with contingency management for hoarding disorder. J. Obsessive Compuls. Relat. Disord. 12, 78–86. doi: 10.1016/j.jocrd.2016.12.005

Keywords : process-based therapy, case study, processes of change, network analysis, process-based approach

Citation: Ong CW, Hayes SC and Hofmann SG (2022) A process-based approach to cognitive behavioral therapy: A theory-based case illustration. Front. Psychol. 13:1002849. doi: 10.3389/fpsyg.2022.1002849

Received: 25 July 2022; Accepted: 10 October 2022; Published: 25 October 2022.

Reviewed by:

Copyright © 2022 Ong, Hayes and Hofmann. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Clarissa W. Ong, [email protected] ; Steven C. Hayes, [email protected] ; Stefan G. Hofmann, [email protected]

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

Organizing Your Social Sciences Research Assignments

  • Annotated Bibliography
  • Analyzing a Scholarly Journal Article
  • Group Presentations
  • Dealing with Nervousness
  • Using Visual Aids
  • Grading Someone Else's Paper
  • Types of Structured Group Activities
  • Group Project Survival Skills
  • Leading a Class Discussion
  • Multiple Book Review Essay
  • Reviewing Collected Works
  • Writing a Case Analysis Paper
  • Writing a Case Study
  • About Informed Consent
  • Writing Field Notes
  • Writing a Policy Memo
  • Writing a Reflective Paper
  • Writing a Research Proposal
  • Generative AI and Writing
  • Acknowledgments

A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

  • The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
  • The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
  • The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
  • The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
  • The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

  • What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
  • Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
  • What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
  • How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

  • Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
  • Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
  • Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
  • Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
  • Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
  • Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
  • Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

  • If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
  • If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
  • Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

  • << Previous: Writing a Case Analysis Paper
  • Next: Writing a Field Report >>
  • Last Updated: Feb 8, 2024 10:20 AM
  • URL: https://libguides.usc.edu/writingguide/assignments
  • Bipolar Disorder
  • Therapy Center
  • When To See a Therapist
  • Types of Therapy
  • Best Online Therapy
  • Best Couples Therapy
  • Best Family Therapy
  • Managing Stress
  • Sleep and Dreaming
  • Understanding Emotions
  • Self-Improvement
  • Healthy Relationships
  • Student Resources
  • Personality Types
  • Verywell Mind Insights
  • 2023 Verywell Mind 25
  • Mental Health in the Classroom
  • Editorial Process
  • Meet Our Review Board
  • Crisis Support

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."

case study in theory

Cara Lustik is a fact-checker and copywriter.

case study in theory

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."

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • View all journals
  • My Account Login
  • Explore content
  • About the journal
  • Publish with us
  • Sign up for alerts
  • Open access
  • Published: 18 February 2024

Wavelet-based information theory in quantitative assessment of AFM images’ quality

  • Bartosz Czesław Pruchnik 1 ,
  • Piotr Adam Putek 1 &
  • Teodor Paweł Gotszalk 1  

Scientific Reports volume  14 , Article number:  3996 ( 2024 ) Cite this article

Metrics details

  • Imaging techniques

The quantitative assessment of the image quality produced by atomic force microscopy (AFM) is an ongoing and challenging task. In our study, we demonstrate Shannon’s application of information theory for measuring image quality. Specifically, we propose quantifying the loss of image information due to the various distortion processes by exploring the relationship between image information based on the information channel capacity (ICC), spectral image representation, and visual quality. Since the ideal image is unavailable, the power and noise spectrum, the critical input information for the image quality evaluation, must be robustly estimated in the proposed method. The classical, most popular Welch method for spectral estimation uses an average of several windowed periodograms and can produce biased spectrum estimates. Therefore, in our work, we discuss an alternative technique based on the wavelet transform that can be applied to solve this challenging problem, specifically in the case of noisy, uncertain AFM measurements. Finally, we validate the performance of the enhanced ICC-wavelet-based algorithm with noisy measurement AFM data.

Introduction

Scanning probe microscopy (SPM) based technologies, including atomic force microscopy (AFM), have been broadly applied for studying the electrical, mechanical, and other properties of metals, semiconductors, dielectrics, or organic structures. Appropriate signal acquisition can analyse the properties of a sample under consideration. Measurements of force are performed indirectly. The cantilever used in the process is the force-displacement transducer; therefore, measurement is vulnerable to the influence of any external forces. Consequently, uncertainties involved in a measurement process may have various origins. Temperature changes affect the sensor and the sample, changing the noise properties and dimensions. Acoustic noises generated by machines and human activity result in the displacement of the mechanical parts of the detector, influencing the measurement. Electromagnetic noise is constantly present in the background and interferes with the electronic part of the system in the broad spectrum of frequencies. Although several means are undertaken in the system’s design, noises can only partially be sorted out. Therefore, a need emerges to assess the level of noise affecting the measured information quantitatively.

In the past two decades, image quality assessment methods have gained increasing attention from academics and industry for their wide applications in many fields, including compression, fusion, registration, and reconstruction 1 . Concerning used measures, approaches for image quality evaluation can be classified as quantitative and qualitative techniques. These studies focus on the former method, which applies the information-based capacity criterion by Shannon 2 for image quality assessment in the AFM 3 . More specifically, there are three inspired by information theory approaches to visual quality assessment (QA): (i) with a complete reference model, (ii) with a reduced reference model, (iii) and a no-reference image 4 , 5 . The availability of reference information has important practical implications in designing the algorithm for the QA of images. This paper deals exclusively with a no-reference quality assessment method for AFM images.

The AFM image quality is metrologically defined as the trueness of the created topographic map to the original surface. There are numerous possible discrepancies, which will be elaborated on in the following sections. More precisely, due to the measurement procedure in a noisy environment, AFM images can suffer numerous artifacts, such as a dust particle stuck to the tip, a drift, the proportional-integral-derivative (PID) loop going haywire, the sudden tip-sample interaction changes during scanning, to stay with a few. As a result, certain factors decrease the signal-to-noise ratio (SNR), while others can keep SNR-like measures unchanged or even enhance them. For instance, on the one hand, the drift might completely ruin measurements of the grating period, but on the other hand, it may be a minor problem for roughness measurement. The precisely opposite effect brings, for example, tip convolution. Besides, a roughness measurement may have significant lateral positioning errors that will not affect the desired measurement result. Moreover, image quality includes imperfections that influence spatial imaging, reducing spatial resolution. Thus, in our work, we focus predominantly on the influence of the Gaussian-like noise on the AFM procedure, mimicking certain aspects of a harsh environment with a Gaussian-like noise model.

The maximum capacity of the information channel (ICC) by Shannon 2 , furthermore generalized in 6 , is explored. According to information theory, the Shannon capacity of a communication channel refers to the maximum amount of error-free information that can theoretically be transferred over the channel without error. From a purely abstract viewpoint, the imaging procedure can be seen as an instance of a communication process. Therefore, assuming that image quality is proportional to the ICC measure, related to the modulation transfer function (MTF) and the level of a perturbed noise 4 , 5 , 7 , 8 , this technique can also be used for image quality evaluation. In particular, Shannon’s metric was also successfully used in 3 to measure the quality of the AFM imaging process quantitatively. However, this measure might be biased due to the uncertainty of the power spectrum estimator. Thus, choosing the right spectrum analysis tool might be challenging. The state-of-the-art spectrum estimation methods are periodogram 9 , Blackman-Tukey 10 , Welch 11 and Multi-taper approach 12 . Since the ICC measure might be prone to measurement noise, the wavelet method seems to be a superior tool for spectrum estimation 13 .

On the one hand, this paper’s main contribution is to enhance the assessment method for the quality of the AFM imaging process. On the other hand, an equally important objective is to provide robust spectral estimates from noisy, uncertain AFM measurements, enabling the extraction of a reliable AFM image spectrum. A spectrum estimation approach based on a wavelet transform is proposed for these reasons. The main challenge for wavelets in this application lies in their capability to deal with singularities and irregular structures apart from the trade-offs they offer in terms of varied metrics, including frequency resolution and variance of the estimated power spectrum 14 , 15 . According to the author’s best knowledge, applying the wavelet transform to quantitative AFM image assessment in the context of information theory has not been studied yet in the proposed framework.

AFM image quality assessment

In the case of the AFM technique, the signal-to-noise ratio (SNR) plays a crucial role in assessing image quality apart from the MTF. However, calculating those parameters requires measurements on a specially prepared so-called reference sample, which might seem complicated due to manufacturing uncertainties. Moreover, information on the potential improvements in image quality is often demanded in the early stage of the measurement process. For instance, it allows for calibrating the AFM setup. For this purpose, a single parameter methodology was proposed in 3 , which allows for quantitative image quality assessment. Another solution, developed in 16 , relies on estimating the normalized power spectrum’s variance, which requires recording images with relatively high SNR values.

Information channel capacity as image quality measure

The visual quality quantification process is crucial to various image and video processing applications, including AFM measurements. Within this context, we propose measuring the loss of image information due to the various distortion processes by exploring the relationship between image information based on the information theory by Shannon 17 , its spectral representation, and visual quality. In the following, likewise, as in 4 , 5 , 7 , we presume that Shannon’s information capacity could measure perceived image quality determined by the MTF and noise. As a result of this assumption, the imaging procedure is seen in our work as an instance of a communication process. Consequently, Shannon’s information channel capacity (ICC), which is a function of both bandwidth \(\mathscr {W}\) and the signal-to-noise ratio \(\left( {\frac{{\mathcal{S}}}{{\mathcal{N}}}} \right)\) , can be treated as a suitable measure for image quality assessment 3 , 4 , 5 , 7 , 16 , 18 .

According to Theorem 2 , from 2 , the complete one-dimensional equation for Shannon capacity, derived for the signal perturbed by the white thermal noise of power N in the band \(\mathscr {W}\) , is given by

with resulting units of information expressed in bits per second, \([\mathrm b/ s]\) , where \(\mathscr {S}\) denotes the mean power of a signal. The straightforward generalization of Eq. ( 1 ) to the case of the arbitrary Gaussian noise, reads as 2 , 3

where \({\xi }\) denotes the frequency of the spectral component of \(\mathscr {S}({\xi })\) and \(\mathscr {N}({\xi })\) , respectively. More specifically, in Eq. ( 2 ), the signal and noise power spectrum under the Gaussian assumption can theoretically be estimated by \(\mathscr {P}({\xi }) = \sigma ^2[\mathscr {S}_{\textrm{ideal}}({\xi })]\) and \(\mathscr {N}({\xi }) = \sigma ^2[\mathscr {N}({\xi })]\) with variance denoted by \(\sigma\) , respectively. In particular, we suppose that the measured signal includes noise that results in \(\mathscr {P}({\xi })+\mathscr {N}({\xi })=:\sigma ^2[\mathscr {S}({\xi })]\) . Finally, we conclude that, as in 2 , 17 , in our notation \(N({\xi })\) denotes the noise measured in the presence of signal \(S_{\textrm{ideal}}({\xi })\) (not narrow-band noise of frequency \(({\xi })\) ). Furthermore, it is also worth noting that in Eq. ( 2 ), the predominant measure of ICC corresponds to the SNR values, while the bandwidth \(\mathscr {W}\) is a result of signal representation only. In addition, the uncertainty of the tested sample design results in uncertainty of its spectrum. Nevertheless, under the assumption that the white model noise is appropriate for the slow scan axis due to the relatively long measurement time, ICC is finally estimated by

where \({{\mathscr {S}}_{N}({\xi })}\) refers to the power spectrum of the noisy signal, and \(\mathscr {F}[\,\cdot \,]\) is the function filter responsible for the thresholding operation of values smaller than 1 to avoid integration of negative values of logarithms due to the uncertain power spectrum estimator.

Moreover, one-dimensional Eq. ( 3 ) can straightforwardly be adjusted to a 2D case

where u and v denote the spectral component frequency in x and y direction, respectively. Correspondingly, after using a polar coordinate system with the spectral radius denoted by

with unit (μ m −1 ) and considering the weak dependence \(\mathscr {S}\) and \(\mathscr {N}\) on \(\theta\) , it can finally be transformed into an equation in one dimension as

with \(\kappa ={2\pi }\) and the constant level of white noise denoted by N . The transformation defined by Eq. ( 6 ) can also be justified by the fact that significant variation is predominantly concentrated at specific scales in the centre of the 2D power spectrum. Thus, the one-dimensional power spectrum is expressed as

where \(\mathscr {S}^{\textrm{2D}}_{\mathscr {N}}[\cdot]\) denotes the 2D centred power spectrum, approximated by Eq. ( 8 ). The unit of the estimated \(\mathscr {C}^{1D}_{r}\) is given in bits per μm (b/μm). It shows the maximum amount of bits of information that (b/μm) of the scanned distance can transmit 3 . The appropriate reduction of the dimensionality through equivalence classes was also recommended by 2 , 7 , 17 . There exist varied methods which allow for estimating the power spectrum \({{\mathscr {S}}_{N}}({\xi })\) for example, the periodogram technique 9 , the Blackman-Tukey method 10 , and the Welch approach 11 . Another group of algorithms for the power spectrum estimation is the multitaper spectrum estimator proposed by Thomson 12 and its natural extension, the wavelet packet approach 13 .

Fourier transform-based method for power estimation

The common feature of the first group method 9 , 10 , 11 to estimate the power spectrum is the usage of the two-dimensional (2D) Fourier transform. Denote by \(g(x, y) \in L^2(\textbf{R}^2)\) a square-integrable function whose domain is the spatial location within an image located at coordinates, ( x ,  y ), and whose gray level intensity range at this location is bounded by \(0 \le I_v \le 255\) . Here, 0 is related to black, while 255 corresponds to white. The exemplary result of the AFM measurement is depicted in Fig.  1 . It is treated in our research as the case study for it is not burdened with purposely generated noise. In the experimental part, samples were measured in three different configurations using various intensities of correlated noise. Only based on them the actual information channel capacities were calculated, contributing to the case study. Out of conducted measurements and calculations, several are presented as appendices to the manuscript.

figure 1

Example of AFM measurement result.

In the classic approach, measurement data g ( x ,  y ) are transformed by a windowed 2D Fourier transform given in the continuous form by 19 , 20

with \(j=\sqrt{-1}\) , \(x_1 = nx_0, y_1 = my_0, u = lu_0,\) and \(v = pv_0\) , \(n,m,l,p \in \textbf{N}\) , where \(\circ\) represents an windowing operator with the window function denoted by h ( x ,  y ).

Furthermore, the application of Parseval’s theorem, which asserts that the Fourier transform preserves energy, yields the estimation of the power spectrum

with the standard \(\ell ^2\) -norm (the Euclidean norm) defined by \(|\cdot |\) . It is a well-known fact that the result of the power estimation depends strongly on the window function to be used 9 . In the simplest form, the periodogram utilizes a rectangular window. However, its counterpart in the frequency domain is a \({\sin}c\) function, which results in a high sidelobe and significant leakages in the power estimates. For this reason, a window function with a taper that smoothly decays on both sides is used 21 , for example, Hamming, Blackman-Harris, Tukey and Blackman. The second serious issue with estimating power spectral density with the periodogram is that it results in significant variance and low precision, which cannot be alleviated using more data. The averaging operation of power spectral density is often used as a remedy. The so-called Blackman-Tukey method and the Welch periodogram originated from this idea. For instance, the 1D power spectrum was calculated using Eq. ( 7 ) for both presented methods and shown in Fig.  2 a and b, respectively.

figure 2

1D power spectrum with varied windows function calculated for the case study sample: ( a ) 2DFFT periodogram; ( b ) Welch periodogram method.

In addition, we also investigated the influence of wavelet denoising properties on the smoothness of the 1D power spectrogram calculated by either the standard 2DFFT periodogram or the Welch periodogram method (WPM). However, since the noise reduction procedure can also remove information while reducing N ( f ) at high spatial frequencies below its proper appriori unknown value, and therefore, potentially affecting the MTF (sharpness) of the image, information capacity measurements should be analyzed with caution. Results of filtering 2D AFM image of the case study sample when using the biorthogonal wave function (Specifically, in our computation, (bior4.4) has been used for filtering 2D AFM image which is implemented in MATLAB filter bank.) 23 are depicted on Fig.  3 a and b, respectively. Since a spike on a relatively smooth power spectrum curve can be easily identified, one can find the cutoff frequency and then estimate the noise level as the average value of the flat part of the spectrum 24 . This might, in turn, allow for designing a fully automated algorithm for the quality assessment of AFM images.

figure 3

1D power spectrum with varied windows function and additionally denoised with the aid of a biorthogonal wavelet (bior4.4) calculated for the case study sample: ( a ) 2DFFT periodogram; ( b ) Welch periodogram method.

Wavelet-based approach for power estimation

The multitaper spectrum estimator is another solution that improves vorticity and reduces sidelobe and leakage by developing a set of orthogonal tapers or windows 25 . The wavelet-based approach for spectral estimation is the natural extension of that method, which also uses different orthogonal decompositions as prototype filters 14 , 15 . In the continuous form, a two-dimensional mother wavelet, \(\psi (x,y)\) with dilatation and translation controlled by \((a_1, a_2)\) and \((b_1, b_2)\) , respectively, is defined as 20

where \(a_i,b_i \in \textbf{R}\) and \(a_i \ne 0\) . Analogously as in the case of the Fourier transform, Parseval’s theorem in the wavelet framework states as

with \(\overline{u}(x)\) corresponded to a complex conjugate of u ( x ), where the Fourier transform of the wavelet function is given as

Form Eq. ( 11 ) it can be concluded that the wavelet transforms also preserves energy conservation. However, the definition of the wavelet power spectrum as the squared amplitude of the wavelet transform 26 might be troublesome from a physical perspective due to units. Besides, the power wavelet spectrum calculated this way might be distorted and biased in terms of large scales 27 . A few solutions to this problem are given in 28 , 29 . In the end, the two-dimensional wavelet transform of g ( x ,  y ) is given by 20

In the case of the wavelet transform, calculating a wavelet radius requires only averaging the resulting matrix versus other parameters such as a or \(\theta\) . Many distinct types of wavelets 26 have found a broad application in the image and signal processing 14 , 15 , 23 . In particular, selecting an appropriate wavelet function, \(\psi\) is a crucial issue when comparing the radially averaged Fourier power spectrum against the global wavelet power spectrum 30 , 31 . It results from the fact that this function determines the distribution of the wavelet spectrum. A wide wavelet function provides a more smooth spectrum due to a similarity measure (a scalar product) between each frequency signal component and the windowed wavelet function, which is used for power spectrum estimation. Specifically, the well-known Morlet type wavelet, 27 , 28 , which employs more sinusoidal cycles than other wavelet transforms to form the analyzing wavelet, seems particularly attractive for this purpose 29 , 32 . Moreover, since the Morlet wavelet transform is defined in the complex domain, the Morlet power spectrum and the Fourier spectrum can be interpreted similarly. The 2D Morlet complex wavelet (or Gabor wavelet) consists of a complex exponential, which is multiplied by a Gaussian window with associated directional dependence as 33

with \(\sigma \in \mathbb {R}\) , \(\omega _0 \in \mathbb {R}\) , \(\varepsilon \in \mathbb {R}\) . To fulfill the admissibility condition \(\omega _0 = 5.336\) 31 .

Another type of wavelet used for a power spectrum analysis is a Fan wavelet function, which is, in essence, a summation of several directional 2D Morlet wavelets spaced along with different directions to have a direction insensitive amplitude response 34 . Thus, the superposition of the Morlet wavelet is average 32

over a finite number of directions with \(\theta _i = \theta _0+i\delta \theta\) , where \(\delta \theta =16.29^{\circ}\) for \(\omega _0 = \pi \sqrt{2/ \ln 2} \approx 5.336\) . In work 32 reported that the Fan and Morlet wavelets belong to the most successful in reproducing the Fourier power spectra. It can be explained by pointing out that these wavelets are, in the space domain, complex exponentials modulated by a Gaussian envelope, which are, in fact, very similar to the Fourier basis functions. For instance, the wavelet-based spectrum using varied mother wavelet function is compared to the classic 2DFFT periodogram technique in Fig.  4 .

figure 4

Wavelet spectrum compared to standard 2DFFT periodogram.

The following section uses Fourier and wavelet transform for 1D spectrum estimation of AFM images.

Numerical results and discussion

The proposed wavelet-based ICC method for AFM quality assessment was verified using three data series , which include an academic benchmark with generated noised synthetic data, and the analyzed referenced sample affected by two type of various noise sources.

Benchmark with synthetic white noise

To validate the procedure for assessing image quality based on ICC metrics compound with various spectral analyses, we generated artificially an image, shown in Fig.  5 , which served as the academic test case. The artificial surface described with the sawtooth signal profile was generated because of a resemblance to the actual measured sample. It was further burdened with white noise generated by a pseudo-random numbers generator recalling the values from a tabularized Gaussian distribution. The matrix of resulting noise was normalized to values of signal-to-noise ratio in the range of 10, 1 and 0.1 dB and subsequently summed with corresponding values of the surface model.

figure 5

Image generated artificially with various level of synthetic white noise in the range of 10, 1 and 0.1 dB.

Furthermore, we applied the formula ( 3 ) with the 2DFFT periodogram with \(i,j=0,\ldots , P\) , \(P=255\) , Welch periodogram, and wavelet-based method to estimate the ICC metric. As recommended in 27 , 29 , 32 , we have used the Morlet and Fan wavelets \(\psi _{\textrm{M}}(6,1,1)\) and \(\psi _{\textrm{F}}(6,1,1,8)\) to calculate the wavelet-based power spectrograms, defined by ( 13 ) with ( 14 ) or ( 15 ). For this reason, following 26 , we have specified the simulation setup: \(s = s_02^{j/J}= [1,\ldots ,180.76]\) with the smallest resolvable scale given by \(s_0=1.0144\) and an integer \(j=[0,\ldots ,J]\) corresponding to the level number with \(J=363\) , and, finally, a uniform grid for \(\theta = l\pi /L = [0,\ldots ,3.115]\) with \(l=0,\ldots , L\) , \(L = 63\) .

Furthermore, to approximate the ICC measure ( 7 ), we used the classic trapezoidal method with \(N+1\) evenly spaced points 22 , 35

with a posteriori error estimation given by

where for the last term of ( 17 ), an asymptotic error estimate for \(N\rightarrow 0\) is conducted with \(\eta =-\pi /6\) and the first and second derivative denoted by \(f', f''\) , respectively. Please note that the approximation error is proportional to \(\xi _h^2\) and depends on the regularity of spectrum given by \(f(\xi )\) .

However, if a (spectrum) function \(f(\xi )\) has no bounded a second derivative, i.e. is only a ’rough’ continuous function, the error bound given by ( 17 ) is not applicable any more. In such a case, the following sharp error bound for the trapezoidal rule has to be applied 36

where \(\sup\) and \(\inf\) denotes suppremum and infimum over a set I , respectively.

In fact, since the spectral analysis has been applied to the sawtooth signal profile, we suppose that the sharp error bound given by ( 18 ) is the reliable error estimation. Finally, the results with error analysis provided by ( 18 ) estimate are listened in Table 1 . In summary, we can conclude that based on the provided error analysis, the ICC measure wavelet approximation seems less biased than those estimations provided by Welch and 2FFT periodogram method, at least for a moderate, practically occurred noise levels. It is strictly related to the regularity of the integrand and the grid size used for the integration.

The artificially generated test case allows us to demonstrate the applicability of the proposed approach in the more challenging measurement setting.

AFM measurements

The first part of the measurement was performed with a white noise signal, in which the root mean square (RMS) value was changed from 0 to 20 V with 5 V step. In the second part, acoustic noise was delivered to the system. The varied music tracks were played during the measurement, acting as the known noise source.

All measurements were performed in contact mode with a sinusoidal speed profile. The speed was one line per second. The scanned area of samples was specified either as 2 by 2 (μm) or 1 by 1 (μm). The reason for the change in sample area was to alter the frequency of details in the topogram. Therefore, the results consisted of a series of AFM images with different noise levels.

Noise modelling

In our paper, two types of noise inputs were utilized to test the influence of types of external noise sources. A distinction is made between white noise and nondeterministic noise. Electronic processing of the signal burdens it with wideband noises. Those wide spectral signals are often referred to as noises of different colours due to similarities to the light spectrum. Among them is white noise, which characterizes the equal distribution of spectral density over all spectrums. This noise was used to elevate the background noise level in the spectrum homogeneously. Moreover, we applied a generator embedded in the function generator to generate white noise. The noise was generated with different RMS values: 5, 10, 15, and 20 V. The results are to be consulted in the appendix Fig. 1 .

Music samples were used to simulate natural noise background in the environment with people. The main concern of this measurement was not necessarily a quantitative assessment of the noise level but the ability to differentiate topograms influenced by different types of music, representing different types of background noises. For that purpose, a few pieces of music were used. They were varied from classical music: “ Étude Op. 10, No. 12 ” by F. Chopin, “ Piano Concerto no. 4 ” by S. Rachmaninoff, “ Symphony No.9 by A. Dvorak, “ Ride of the Valkyries ” by R. Wagner, to the modern rock and heavy metal: “ You Can’t Teach An Old Dog New Tricks ” by Seasick Steve, “ Stargazers ” by Nightwish, and “ Chippin’ in by Samurai. Indeed, different music sounds should contribute differently to the overall noise spectrum. The effect of AFM measurement are to be acquainted with in the supplementary material.

The influence of narrowband noises, which come from mechanical sources, especially motor drives present in pumps, fans, and generators - devices characterized by constant engine speed - is not considered in our paper.

Quantitative assessment of AFM images’ quality

The AFM images of the reference sample were measured to demonstrate the performance of the proposed quality assessment method. These reference samples’ topographies look similar in various configurations of the noise excitation. However, differences in AFM images might be rather identified and assessed qualitatively. A power spectral analysis of images may support the rough observations. For this reason, the ICC-based measure, whose calculation procedure was described in Section " Information channel capacity as image quality measure ", was used to assess the quality of the recorded AFM images. The methods for the power spectra estimation, including the 2DFFT periodogram, the WPM, and the wavelet-based periodogram technique, described in Section " AFM image quality assessment ", were implemented in Matlab \(^{\circledR }\) 22 . The implementation of the ordinary periodogram method with the use of the 2DFFT routine and varied windows function has been straightforward.

figure 6

Radial power spectrogram from calculated 2DFFT of reference sample using Blackman-Harris window for: ( a ) white noise; ( b ) music as noise model.

The WPM provides the power spectral density estimate with the aid of overlapped segment averaging estimator, where each segment can be windowed with various types of windows, as stated in Section  Fourier transform-based method for power estimation . In our simulations, we considered the maximal size of the segment of 256 by 256 with 50 \(\%\) overlap. Furthermore, for mapping the resulting 2D power spectra into the 1D space, we used Eq. ( 7 ). In the end, the 1D power spectral density plots were prepared for all gathered AFM images with the various source of noise as described in Section  Noise modelling . Furthermore, since the spectral analysis provided by the standard 2DFFT periodogram and the WPM look similar, specifically compared to the wavelet-based spectra, only the results for the 2DFFT power spectrum are presented in Fig.  6 a and b, respectively.

figure 7

Wavelet power spectrum calculated for reference sample using Morlet wavelet \(\psi _{\textrm{M}}(6,1,1)\) for: ( a ) white noise; ( b ) music as noise model.

As to the wavelet-based power spectrograms, we applied the Morlet and Fan wavelets as recommended in 32 . In our simulations, the fast Morlet and Fan wavelet transform 27 , 29 was used for wavelets \(\psi _{\textrm{M}}(6,1,1)\) and \(\psi _{\textrm{F}}(6,1,1,8)\) . For convenience, we defined scale s as base 2 exponentials 26 , that is, \(s = s_02^{j/J}= [1,\ldots ,180.76]\) , \(s_0=1.0144\) denoted the smallest resolvable scale and an integer \(j=[0,\ldots ,J]\) representing the level number with \(J=363\) . However, we used a uniform grid for \(\theta = l\pi /L = [0,\ldots ,3.115]\) with \(l=0,\ldots , L\) , \(L = 63\) . To demonstrate the improvements of the wavelet-based method, we compare the 1D wavelet power spectrum results shown in Fig.  7 a and b with those provided with the 2DFFT method (cf. Fig.  6 a and b) using noised AFM images. It should be noted that the resulting wavelet power spectra’ smoothness properties, on the one hand, allow for automatizing the ICC-based metric of AFM images. For example, a simple procedure for finding an inflection point can be used to identify the background noise. On the other hand, the wavelet-based ICC estimation quality can be significantly improved since the cutoff frequency can be precisely found. In our work, similarly to 24 , the noise level was estimated as the mean value of the flat part of the spectrum \(S_{\textrm{N}}(\xi )\) . Finally, we explored the ICC metrics proposed in 24 , defined by Eq. ( 6 ) with \(\kappa =2\pi\) to assess the quality of the recorded AFM images quantitatively. The ICC-based metrics calculated for all gathered AFM images are listed in Tables  2 and 3 , respectively.

Adopting the Shannon theorem from the telecommunication technologies 2 , the higher values of ICC will specify the higher quality image. This conclusion results from the fact that the amount of error-free information that may be transmitted through the channel is determined by the bandwidth of the communication channel and the signal-to-noise ratio. In our work, we mainly focused on studying the influence of the signal-to-noise ratio as the limitation for the amount of error-free information. In fact, even a cursory examination of Table  2 allows for verifying this theorem in the context of spectral analysis of AFM images: a higher level of noise limits the quality of images. Even though the ICC metrics computed based on three studied methods for power spectra estimation are consistent, the less biased ones seems to be those provided by the wavelet-based method. It results from the fact that background noise can be identified more precisely when considering a smooth continuous spectrum, which might improve the calculation reliability based on the formula ( 3 ).

Furthermore, the ICC measure can also be applied to a noise model, which is random but not equally distributed in the frequency spectrum noise model (cf. Fig.  7 a and b). An example of such a noise is music, which was used to simulate a noise produced by a human. Undoubtedly, music, being not perfectly described ambient noise source (especially considering its spectrum), is more of a qualitative indicator and a means to provide noise-differentiated samples into exemplary calculations. Also, in this case, the resulting ICC values summarized in Table  3 produced by three different methods show convergence.

Experimental procedures and methods

Principles of afm operation and sample characterization.

SPM techniques, including electrostatic force microscopy (EFM) or AFM, have found broad application in analyzing the surface properties of varied materials 3 , 19 . AFM belongs to the SPM family, whose main principle of the measurement is detection of a singular interaction between the probe and the surface - so called atomic forces. Microcantilevers are most often used as probes. In contact mode, a change in sample height is detected by bending a probe by imposing a constant force. Typically, in non-contact mode, a change in the amplitude or frequency of the cantilever vibration is sought, which does not cause surface wear. Additionally, there is no lateral contact force between the probe and the surface, so it is possible to investigate more fragile surfaces (e.g., biofilms, proteins) in this mode 37 . Among the AFM modes, there is also a place for mixed techniques, which combine properties of both contact and non-contact, e.g., a tapping mode in which the probe touches the surface only at specific points, see, e.g., for details 38 , 39 , 40 , 41 , 42 .

Experimental set-up

In our studies, we applied the AFM system for contact measurements with an optical beam deflection (OBD) in the experiment. The purpose of conducting measurements was to register signals with different noise levels. A typical AFM system registers low-band signals - in this case, the upper band limit is 10 kHz, therefore the actuator should have a band broader than from 0.1 to 10 kHz and be applied to the cantilever as closely as possible. Both demands are satisfied by a piezoelectric chip actuator. In our research, we used the Thorlabs piezoelectric chip PA4HEW. A phosphor bronze spring held it together with the cantilever in the holder. Schematics of the setup are presented in Fig.  8 . The signal to the piezoelectric chip was delivered from the signal generator Tektronix AFG3021B via the infinite impulse response (IIR) low-pass filter with a cutoff frequency 10 kHz. The filter was necessary to eliminate a resonance of the piezoelectric chip (165 kHz).

In the further phase of our research, we slightly modified the setup to assess the impact of typical acoustic noises on the measurement process. Even though, music usage may seem nonintuitive, we have found it a useful noise source for several reasons. Specifically, we considered music the least consistent noise source, being chaotic in some sense while remaining in a typical frequency range for human activity; concurrently, it is repeatable and of somehow controlled characteristics. The choice of different pieces from different music genres pushed randomization even further, excluding the domination of one set of frequencies. Therefore, it states the intermediate step between a deterministic noise source and an entirely stochastic model. In our case, during the measurements, a noise was emitted with speakers ZX-SPACE ZoltriXound connected to the PC shown in Fig.  9 . Speakers were chosen to simulate a noise background typical for the presence of people in the surroundings. They were to emit noise in the acoustic subspectrum between 20 and 10 kHz.

We analysed the same surface in all measurements, SiC with 1.5 nm atomic steps calibration sample. The used cantilevers was a model PPP-CONTSCPt by NANOSENSORS™. They belong to the family of typical contact probes with resonant frequency in the range 1–57 kHz (typically 25 kHz), force constant between 0.01 and 1.87 N/m (typically 0.2 N/m) and full PtIr coating.

figure 8

Measuring setup schematics: ( a ) block diagram of used devices and transmitted signals; ( b ) cross-section through a cantilever holder with the included piezoelectric chip (not to scale).

figure 9

Measuring setup with a source of synthetic acoustic noise and frequency spectrum as measured on cantilever deflection signal for continuous 50 Hz acoustic noise.

The measurement setup offers a sensitivity of 125 nm/V, derived from calibration sample measurements. However, the information capacity of a scanned surface is invariant concerning the transformation of measurements from the voltage to the height domain. In fact, we could even operate on unaltered values as given by the measurement setup.

Measurements performed with the AFM at lower resolutions are highly vulnerable to external noises, which can be present in different forms. In all electronic systems, electrical noises are always present 2 , 3 , 24 , yet, the progress in the field of integrated circuits decreases the influence of those noises. Another source is the construction of actuators for height compensation. In dedicated systems, noises are well-characterized and relatively low. The laser detector light is a typical noise source, apart from the mechanical construction (inert elements, material creep) or temperature (thermal expansion, parasitic thermal deflection). External mechanical noises of acoustic and sub-acoustic frequencies seem most influential. Despite active and passive methods of mechanical noise damping, those signals are frequently observed in measurements.

Acoustic noises consist of harmonic and impulse signals, whereby harmonious signals can be filtered out entirely with active and partly with passive damping. Active vibration cancelling relies on generating signals identical to noise in a reversed phase to cancel both signals in superposition. The passive damping is acoustic filtering, so the system’s physical properties limit the filtered band. Another purpose of passive filtering is, on the one hand, to shift the system’s resonant frequency as low as possible to eliminate the possibility of resonant excitation. On the other hand, impulses are easily damped by passive filtering and are impossible to eliminate with active filtration. Nevertheless, harmonious and impulse noises are finally present in the resulting picture.

In the frequency spectrum, noises are visible as peaks corresponding to specific frequencies (mainly harmonious noises), constant band elevation (thermal, electric, and mechanical noises, also impulses), and frequency-dependent band elevation (e.g., 1/ f noise).

Our work has briefly explained the methodology of measurements conducted with the AFM setup to address the important problem of the QA process of AFM images, which must be quantitatively assessed to improve the measurement process or find measurements with the highest quality. However, the ideally conducted data series in the sense of the reference measurements do not exist in this case. Therefore, we have had to apply the ICC metric, adopted from telecommunication technologies and initially proposed by 24 . In fact, this metric has been widely used in various applications to assess image quality under the assumption to be correlated with MTF and noise 4 , 5 , 7 , 8 . As this measure is predominantly susceptible to signal-to-noise ratio and image resolution, the superior tool for estimating power spectra is the taper wavelet-based method. On the one hand, it allows for estimating background noise that is a source of bias in the ICC metric. On the other hand, it provides a smooth approximation of power spectra, limiting the spectrum distribution uncertainty. For these reasons, the fast Morlet and Fan wavelet methods have been used in our studies. We used data noised by white noise and a random but not equally distributed frequency spectrum noise model for numerical experiments. Thus, based on our numerical experimentation, we claim that the ICC metric, primarily based on the wavelet approach, could be a robust method enabling the metrological assessment of the recorded AFM images 43 . In addition, applying the wavelet-based method for the power spectrum estimation might result in a fully automatic procedure for AFM image assessment.

The wavelet transform can also be perceived as an intermediate step between filtration and spectral analysis, which allows for extracting essential features of AFM images. It is seen as a promising direction for future investigations.

Data availability

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

Wang, Z. & Bovik, A. C. Modern Image Quality Assessment (Morgan & Claypool, 2006).

Book   Google Scholar  

Shannon, C. E. Communication in the presence of noise. Proc. IEEE 86 (2), 447–457 (1948).

Article   Google Scholar  

Kopiec, D., Jóźwiak, G., Moczała, M., Sierakowski, A. & Gotszalk, T. Multifrequency Kelvin probe force microscopy on self assembled molecular layers and quantitative assessment of images’ quality. Ultramicroscopy 194 , 100–107 (2018).

Article   CAS   PubMed   Google Scholar  

Sheikh, H. R. & Bovik, A. C. Image information and visual quality. IEEE Trans. Image Process. 15 (2), 430–444 (2006).

Article   ADS   PubMed   Google Scholar  

Soundararajan, R. & Bovik, A. C. Survey of information theory in visual quality assessment signal. Image Video Process. 7 (3), 391–401 (2013).

Verdú, S. & Han, T. S. A general formula for channel capacity. IEEE Trans. Inf. Theory 40 , 1147–1157 (1994).

Shaw, R. Application of Fourier technique and information theory to the assessment of photographic image quality. Photogr. Sci. Eng. 6 (5), 281–286 (1962).

Google Scholar  

Byrnes, N. & Foreman, M. R. Universal bounds for imaging in scattering media new. J. Phys. 22 , 083023 (2020).

MathSciNet   Google Scholar  

Auger, F. & Flandrin, P. Improving the readability of time-frequency and time-scale representations by the reassignment method. IEEE Trans. Signal Process. 43 (5), 1068–1089 (1995).

Article   ADS   Google Scholar  

Blackman, R. B. & Tukey, J. W. The Measurement of Power Spectra from the Point of View of Communications Engineering - Part I The. Bell Syst. Tech. J. 37 (1), 185–282 (1958).

Welch, P. W. The use of fast Fourier transform for the estimation of power spectra: A method based on time averaging over short. Modified Periodograms IEEE Trans. Audio Electroacoust. 15 (2), 70–76 (1967).

Thomson, D. J. Spectrum estimation and harmonic analysis. Proc. IEEE 70 (9), 1055–1096 (1982).

Vu, D. H. Wavelet-based spectral analysis. Trends Anal. Chem. 62 , 144–153 (2014).

Article   MathSciNet   Google Scholar  

Lakshmanan, M. K., Ariananda, D. D., & Nikookar, H. A reconfigurable wavelet packet filter bank transceiver for spectral analysis and dynamic spectrum access. In 2011 IEEE International Symposium on Dynamic Spectrum Access Networks (DySPAN) 564–575 (2011).

Starck, J.-L., Siebenmorgen, R. & Gredel, R. Spectral analysis using the wavelet transform. Astrophys. J. 482 (2), 1011–1020 (1997).

Article   ADS   CAS   Google Scholar  

Szeloch, R. F., Janus, P., Serafińczuk, J., Szecówka, P. M. & Jóźwiak, G. Characterization of fatigued Al lines by means of SThM and XRD: Analysis using fast Fourier transform microelectron. Reliab. 52 , 711–717 (2012).

Article   CAS   Google Scholar  

Shannon, C. E. A mathematical theory of communication. Bell Syst. Tech. J. 27 , 379–423 (1948).

Levitin, L. B. & Toffoli, T. The capacity of a channel with an image as the information source. J. Quantum Inf. Sci. 4 , 111–116 (2014).

Stern, J., Terris, B., Mamin, H. & Rugar, D. Deposition and imaging of localized charge on insulator surfaces using force microscopy. Appl. Phys. Lett. 53 , 2717–2719 (1988).

Schmeelk, J. Wavelet transforms on two-dimensional images. Math. Comput. Model. 36 , 939–948 (2002).

Lim, J. & Oppenheim, A. V. Advanced Topics in Signal Processing Englewood Cliffs (Prentice Hall, 1988).

MATLAB 9.10.0.1649659 (R2021a). Natick (The MathWorks Inc, 2022).

Daubechies, I. Ten lectures on wavelets. In CBMS-NSF Regional Conference Series in Applied Mathematics (Philadelphia Society for Industrial and Applied Mathematics, 1992)

Jóźwiak, G. et al. The spring constant calibration of the piezoresistive cantilever based biosensor. Sens. Actuators B 170 , 201–206 (2012).

Candy, J. V. Multitaper spectral estimation: An Alternative to the Welch periodogram approach. Technical Report by Lawrence Livermore National Lab: LLNL-TR-788954, United States. https://www.osti.gov/biblio/1560107 (2019).

Torrence, Ch. & Compo, G. P. A practical guide to wavelet analysis. Bull. Am. Meteorol. 79 (1), 61–78 (1998).

Shyu, H. C. & Sun, Y. S. Construction of a Morlet wavelet power spectrum. Multidimens. Syst. Signal Process. 13 , 101–111 (2002).

Büssow, R. An algorithm for the continuous Morlet wavelet transform. Mech. Syst. Signal. Process. 21 (8), 2970–2979 (2007).

Chen, C. & Chu, X. Two-dimensional Morlet Wavelet transform and its application to wave recognition methodology of automatically extracting two-dimensional wave packets from lidar observations in Antarctica. J. Atmos. Sol. Terr. Phys. 162 , 28–47 (2017).

Perrier, V., Philipovitch, T. & Basdevant, C. Wavelet spectra compared to Fourier spectra. J. Math. Phys. 36 , 1506–1519 (1995).

Article   ADS   MathSciNet   Google Scholar  

Kirby, J. F. Which wavelet best reproduces the Fourier power spectrum?. Comput. Geosci. 31 (7), 846–864 (2005).

Kirby, J. F. & Swain, C. J. Power spectral estimates using two-dimensional Morlet-Fan wavelets with emphasis on the long wavelengths: Jackknife errors, bandwidth resolution and orthogonality properties. Geophys. J. Int. 194 (1), 78–99 (2013).

Dallard, T. & Spedding, G. R. 2-D wavelet transforms: Generalisation of the Hardy space and application to experimental studies. Eur. J. Mech. B Fluids 12 (1), 107–134 (1993).

Dehaeck, S., Tsoumpas, Y. & Colinet, P. Analyzing closed-fringe images using two-dimensional fan wavelets. Appl. Opt. 54 (10), 2939–2952 (2015).

Article   ADS   CAS   PubMed   Google Scholar  

Babuška, I., Nobile, F. & Tempone, R. Worst case scenario analysis for elliptic problems with uncertainty. Numer. Math. 101 , 185–219 (2005).

Cruz-Uribe, D. & Neugebauer, C. J. Sharp error bounds for the trapezoidal rule and Simpson’s rule. J. Inequal. Pure Appl. Math. 3 (4), 1–22 (2002).

Sozański, K. et al. A depletion layer in polymer solutions at an interface oscillating at the subnano-to submicrometer scale. Soft Matter 10 (39), 7762–7768 (2014).

Linnemann, R., Gotszalk, T., Rangelow, I. W., Dumania, P. & Oesterschulze, E. Atomic force microscopy and lateral force microscopy using piezoresistive cantilevers. J. Vac. Sci. Technol. B 14 , 856–860 (1996).

Minne, S. C., Manalis, S. R. & Quate, C. F. Parallel atomic force microscopy using cantilevers with integrated piezoresistive sensors and integrated piezoelectric actuators. Appl. Phys. Lett. 67 (26), 3918–3920 (1995).

Nieradka, K. et al. Fabrication and characterization of electromagnetically actuated microcantilevers for biochemical sensing, parallel AFM and nanomanipulation. Microelectron. Eng. 98 , 676–679 (2012).

Kunicki, P., Angelov, T., Ivanov, T., Gotszalk, T. & Rangelow, I. W. Sensitivity improvement to active piezoresistive AFM probes using focused ion beam processing. Sensors 4429 (19), 1–9 (2019).

Pruchnik, B. et al. Study of the efficiency of microcantilevers: Cases of electrothermal and electromagnetic actuation. J. Microelectromech. Syst. 31 (5), 784–790 (2022).

Gackenheimer, C., Cayon, L. & Reifenberger, R. Analysis of scanning probe microscope images using wavelets. Ultramicroscopy 106 (4–5), 389–397 (2006).

Download references

Acknowledgements

The National Science Centre has supported this work, Poland OPUS grant “ Nanometrology of Nottingham cooling effect using operational microelectromechanical systems ” under project contract no. 2020/37/B/ ST7/03792.

Author information

Authors and affiliations.

Department of Nanometrology, Faculty of Electronics, Photonics and Microsystems, Wroclaw University of Science and Technology, 50-372, Wrocław, Poland

Bartosz Czesław Pruchnik, Piotr Adam Putek & Teodor Paweł Gotszalk

You can also search for this author in PubMed   Google Scholar

Contributions

T.P.G. introduced the methodology. B.C.P. performed experimental part. P.A.P. performed data analysis and prepared quantifical results. All authors wrote and reviewed the manuscript.

Corresponding author

Correspondence to Bartosz Czesław Pruchnik .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

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

Supplementary Information

Supplementary information., rights and permissions.

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

Reprints and permissions

About this article

Cite this article.

Pruchnik, B.C., Putek, P.A. & Gotszalk, T.P. Wavelet-based information theory in quantitative assessment of AFM images’ quality. Sci Rep 14 , 3996 (2024). https://doi.org/10.1038/s41598-024-53846-y

Download citation

Received : 14 July 2023

Accepted : 06 February 2024

Published : 18 February 2024

DOI : https://doi.org/10.1038/s41598-024-53846-y

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

  • Explore articles by subject
  • Guide to authors
  • Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

case study in theory

Help | Advanced Search

High Energy Physics - Theory

Title: b-brane transport and grade restriction rule for determinantal varieties.

Abstract: We study autoequivalences of $D^{b}Coh(X)$ associated to B-brane transport around loops in the stringy Kähler moduli of $X$. We consider the case of $X$ being certain resolutions of determinantal varieties embedded in $\mathbb{P}^{d}\times G(k,n)$. Such resolutions have been modeled, in general, by nonabelian gauged linear sigma models (GLSM). We use the GLSM construction to determine the window categories associated with B-brane transport between different geometric phases using the machinery of grade restriction rule and the hemisphere partition function. In the family of examples analyzed the monodromies around phase boundaries enjoy the interpretation as loop inside link complements. We exploit this interpretation to find a decomposition of autoequivalences into simpler spherical functors and we illustrate this in two examples of Calabi-Yau 3-folds $X$, modeled by an abelian and nonabelian GLSM respectively. In additon we also determine explicitly the action of the autoequivalences on the Grothendieck group $K(X)$ (or equivalently, B-brane charges).

Submission history

Access paper:.

  • Download PDF
  • Other Formats

References & Citations

  • INSPIRE HEP
  • Google Scholar
  • Semantic Scholar

BibTeX formatted citation

BibSonomy logo

Bibliographic and Citation Tools

Code, data and media associated with this article, recommenders and search tools.

  • Institution

arXivLabs: experimental projects with community collaborators

arXivLabs is a framework that allows collaborators to develop and share new arXiv features directly on our website.

Both individuals and organizations that work with arXivLabs have embraced and accepted our values of openness, community, excellence, and user data privacy. arXiv is committed to these values and only works with partners that adhere to them.

Have an idea for a project that will add value for arXiv's community? Learn more about arXivLabs .

  • Open access
  • Published: 27 June 2011

The case study approach

  • Sarah Crowe 1 ,
  • Kathrin Cresswell 2 ,
  • Ann Robertson 2 ,
  • Guro Huby 3 ,
  • Anthony Avery 1 &
  • Aziz Sheikh 2  

BMC Medical Research Methodology volume  11 , Article number:  100 ( 2011 ) Cite this article

749k Accesses

885 Citations

38 Altmetric

Metrics details

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Peer Review reports

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Yin RK: Case study research, design and method. 2009, London: Sage Publications Ltd., 4

Google Scholar  

Keen J, Packwood T: Qualitative research; case study evaluation. BMJ. 1995, 311: 444-446.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J, et al: Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009, 6 (10): 1-11.

Article   Google Scholar  

Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, et al: The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). 2008, [ http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf ]

Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al: Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010, 41: c4564-

Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P, the Patient Safety Education Study Group: Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010, 15: 4-10. 10.1258/jhsrp.2009.009052.

Article   PubMed   Google Scholar  

van Harten WH, Casparie TF, Fisscher OA: The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002, 60 (1): 17-37. 10.1016/S0168-8510(01)00187-7.

Stake RE: The art of case study research. 1995, London: Sage Publications Ltd.

Sheikh A, Smeeth L, Ashcroft R: Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002, 52 (482): 746-51.

PubMed   PubMed Central   Google Scholar  

King G, Keohane R, Verba S: Designing Social Inquiry. 1996, Princeton: Princeton University Press

Doolin B: Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998, 13: 301-311. 10.1057/jit.1998.8.

George AL, Bennett A: Case studies and theory development in the social sciences. 2005, Cambridge, MA: MIT Press

Eccles M, the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG): Designing theoretically-informed implementation interventions. Implementation Science. 2006, 1: 1-8. 10.1186/1748-5908-1-1.

Article   PubMed Central   Google Scholar  

Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A: Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005, 365 (9456): 312-7.

Sheikh A, Panesar SS, Lasserson T, Netuveli G: Recruitment of ethnic minorities to asthma studies. Thorax. 2004, 59 (7): 634-

CAS   PubMed   PubMed Central   Google Scholar  

Hellström I, Nolan M, Lundh U: 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005, 4: 7-22. 10.1177/1471301205049188.

Som CV: Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005, 18: 463-477. 10.1108/09513550510608903.

Lincoln Y, Guba E: Naturalistic inquiry. 1985, Newbury Park: Sage Publications

Barbour RS: Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?. BMJ. 2001, 322: 1115-1117. 10.1136/bmj.322.7294.1115.

Mays N, Pope C: Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000, 320: 50-52. 10.1136/bmj.320.7226.50.

Mason J: Qualitative researching. 2002, London: Sage

Brazier A, Cooke K, Moravan V: Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008, 7: 5-17. 10.1177/1534735407313395.

Miles MB, Huberman M: Qualitative data analysis: an expanded sourcebook. 1994, CA: Sage Publications Inc., 2

Pope C, Ziebland S, Mays N: Analysing qualitative data. Qualitative research in health care. BMJ. 2000, 320: 114-116. 10.1136/bmj.320.7227.114.

Cresswell KM, Worth A, Sheikh A: Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010, 10 (1): 67-10.1186/1472-6947-10-67.

Article   PubMed   PubMed Central   Google Scholar  

Malterud K: Qualitative research: standards, challenges, and guidelines. Lancet. 2001, 358: 483-488. 10.1016/S0140-6736(01)05627-6.

Article   CAS   PubMed   Google Scholar  

Yin R: Case study research: design and methods. 1994, Thousand Oaks, CA: Sage Publishing, 2

Yin R: Enhancing the quality of case studies in health services research. Health Serv Res. 1999, 34: 1209-1224.

Green J, Thorogood N: Qualitative methods for health research. 2009, Los Angeles: Sage, 2

Howcroft D, Trauth E: Handbook of Critical Information Systems Research, Theory and Application. 2005, Cheltenham, UK: Northampton, MA, USA: Edward Elgar

Book   Google Scholar  

Blakie N: Approaches to Social Enquiry. 1993, Cambridge: Polity Press

Doolin B: Power and resistance in the implementation of a medical management information system. Info Systems J. 2004, 14: 343-362. 10.1111/j.1365-2575.2004.00176.x.

Bloomfield BP, Best A: Management consultants: systems development, power and the translation of problems. Sociological Review. 1992, 40: 533-560.

Shanks G, Parr A: Positivist, single case study research in information systems: A critical analysis. Proceedings of the European Conference on Information Systems. 2003, Naples

Pre-publication history

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2288/11/100/prepub

Download references

Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

Author information

Authors and affiliations.

Division of Primary Care, The University of Nottingham, Nottingham, UK

Sarah Crowe & Anthony Avery

Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sarah Crowe .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

Download citation

Received : 29 November 2010

Accepted : 27 June 2011

Published : 27 June 2011

DOI : https://doi.org/10.1186/1471-2288-11-100

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

  • Case Study Approach
  • Electronic Health Record System
  • Case Study Design
  • Case Study Site
  • Case Study Report

BMC Medical Research Methodology

ISSN: 1471-2288

case study in theory

Advertisement

Supported by

Abortions by Telemedicine and Mailed Pills Are Safe and Effective, Study Finds

Pam Belluck

By Pam Belluck

Pam Belluck has covered reproductive health for more than a decade.

  • Share full article

Taking abortion pills prescribed through telemedicine and received by mail — a method used by growing numbers of abortion patients — is as safe and effective as when the pills are obtained by visiting a doctor, a large new study found. The method was about 98 percent effective and was safe for over 99 percent of patients, the study reported.

A stack of orange Mifeprex boxes sits next to a stack of plastic cups.

The research

The study, led by researchers at the University of California, San Francisco, looked at the experience of more than 6,000 patients in the months after the federal government began allowing abortion pills to be mailed , from April 2021 to January 2022.

The patients used one of three telemedicine abortion organizations — Hey Jane, Abortion on Demand or Choix — that served 20 states and Washington, D.C. The research, published on Thursday in Nature Medicine, ended five months before the Supreme Court overturned Roe v. Wade, igniting a wave of state abortion bans and restrictions. Since then, more telemedicine services have opened, and are used by many patients who consider the method more convenient, private and affordable than visiting clinics or doctors, especially if they have to travel to another state.

The services in the study prescribed pills to patients who were 10 weeks pregnant or less (one service had an eight-week limit) and screened patients for medical issues that would make them ineligible , like ectopic pregnancies or blood-clotting disorders.

In most cases, the services’ doctors, nurse practitioners, physician assistants and midwives were able to determine eligibility from patients’ written or verbal information about their pregnancy and health, without requiring them to have ultrasounds, which are logistically difficult for some patients to obtain. If medical eligibility was unclear, patients were asked to get ultrasounds — 486 did and were then prescribed pills, comprising about 8 percent of the 6,034 patients who received pills in the study.

The results

Researchers reviewed the medical records of the services and were able to determine abortion outcomes for three-fourths, or 4,454, of the patients. A vast majority — 4,351 patients, or 97.7 percent — completed abortions with the standard regimen: mifepristone, which stops a pregnancy’s development, followed a day or two later by misoprostol, which causes contractions to expel the tissue.

Of the remaining patients, 85 needed additional measures to complete the abortion, usually with additional medication or a suction procedure in a medical facility.

Eighty-one patients visited emergency departments, and 15 patients had serious complications. Ten patients were hospitalized. Six received blood transfusions, two were treated for infections and one had surgery for an ectopic pregnancy.

Six patients turned out to have ectopic pregnancies, which would have made them ineligible for the pills. Studies show that ectopic pregnancies cannot always be identified early, even by ultrasound.

Of the patients who visited emergency departments, 38 percent ended up needing no treatment. Patients sometimes visit emergency departments because “they don’t know whether what they’re experiencing is normal and they sometimes don’t have anyone to ask and they don’t want to tell a lot of people about their abortion,” said Dr. Ushma Upadhyay, a public health scientist at U.C.S.F. and one of the study’s authors.

No patients were found to be beyond 10 weeks into pregnancy.

The effectiveness and safety rates were similar to those in several large studies of in-person medication abortion and of telemedicine abortion where ultrasounds were required . They were also similar to the rates on the Food and Drug Administration’s label for mifepristone .

Researchers also found no difference in safety or efficacy for patients who received real-time video consultations compared to those who received prescriptions based on written information they provided via text messaging, which most patients did.

Two patients asked about “abortion pill reversal,” a nonscientific theory that abortions can be stopped after taking the first drug. Both were told that “evidence-based reversal treatment does not exist” and were referred to urgent in-person care, the study reported.

Larger implications

Medication abortion is being challenged in a lawsuit filed against the F.D.A. by abortion opponents seeking to curtail mifepristone. One of the plaintiffs’ claims is that abortion pills are dangerous. The F.D.A. has cited overwhelming scientific evidence that the pills are safe , and two studies that abortion opponents referenced to support their claims were recently retracted by a scientific journal publisher .

In August, an appeals court said mifepristone could remain legal, but ordered significant restrictions that would prevent mailing or prescribing it by telemedicine. The Supreme Court will hear arguments in the case next month. The new study results may be mentioned by those urging the court to keep telemedicine abortion available.

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

IMAGES

  1. Towards building theories using case study research

    case study in theory

  2. (PDF) The Case For Case Studies: Deriving Theory From Evidence

    case study in theory

  3. A Necessary Dialogue: Theory in Case Study Research

    case study in theory

  4. (PDF) A Key Role for Case Studies: Theory Building

    case study in theory

  5. How To Apply A Theory To A Case Study

    case study in theory

  6. Understanding Case Study, Phenomenological and Grounded Theory Approach

    case study in theory

VIDEO

  1. Theory Introduction

  2. How to study theory subjects?📚#shorts

  3. How To Study Theory Subject

  4. Wiki in Africa case study: theory of change and evaluation

  5. Lesson Study: Theory, Aplication, and Future Research

  6. HOW TO STUDY ANY THEORY SUBJECT ?

COMMENTS

  1. A Necessary Dialogue: Theory in Case Study Research

    We consider two existing approaches to linking case study and theory, an inductive, theory-building approach (theory for the case) and a deductive, theory-testing approach (theory from the case), and propose a bidirectional dialogic approach.

  2. Case Studies in Theory and Practice

    Case Studies in Theory and Practice Timothy Koschmann & Baruch B. Schwarz Chapter First Online: 09 October 2021 2478 Accesses 1 Citations Part of the Computer-Supported Collaborative Learning Series book series (CULS,volume 19) Abstract What sets CSCL research apart is a principled commitment to learning in settings of collaboration.

  3. The theory contribution of case study research designs

    1 Introduction Case study research scientifically investigates into a real-life phenomenon in-depth and within its environmental context. Such a case can be an individual, a group, an organization, an event, a problem, or an anomaly (Burawoy 2009; Stake 2005; Yin 2014 ).

  4. Case Study Methodology of Qualitative Research: Key Attributes and

    A case study is one of the most commonly used methodologies of social research. This article attempts to look into the various dimensions of a case study research strategy, the different epistemological strands which determine the particular case study type and approach adopted in the field, discusses the factors which can enhance the effectiveness of a case study research, and the debate ...

  5. What Is a Case Study?

    Step 1: Select a case Once you have developed your problem statement and research questions, you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to: Provide new or unexpected insights into the subject Challenge or complicate existing assumptions and theories

  6. Case Study Research and Theory Building

    Abstract. The problem and the solution. This chapter overviews case study research and proposes a manner in which case study research can contribute to theory building in applied disciplines. Although theory building using case study research has been discussed previously in the literature, there is no clarity as to how case study research can ...

  7. Case Study

    Revised on 30 January 2023. A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research. A case study research design usually involves qualitative methods, but quantitative methods are sometimes ...

  8. Case Study Research and Theory Building

    The problem and the solution. This chapter overviews case study research and proposes a manner in which case study research can contribute to theory building in applied disciplines. Although theory building using case study research has been discussed previously in the literature, there is no clarity as to how case study research can be used to build theory. Moreover, it should not be assumed ...

  9. Building Theories from Case Study Research on JSTOR

    Kathleen M. Eisenhardt, Building Theories from Case Study Research, The Academy of Management Review, Vol. 14, No. 4 (Oct., 1989), pp. 532-550

  10. Case Studies and Theory Development in the Social Sciences

    Case Studies and Theory Development in the Social Sciences. by Alexander L. George and Andrew Bennett. $35.00 Paperback. Hardcover. eBook. Rent eTextbook. 352 pp., 6 x 9 in, Paperback. 9780262572224.

  11. Case Study Methods in International Relations

    Case Studies and Theory Development in the Social Sciences. Cambridge, MA: MIT, 2005. This text provides an in-depth assessment of case study research design for researchers whose focus is on designing case studies for theory testing. While the first part of the book provides an in-depth overview of social science debates on the merits of case ...

  12. The case study approach

    In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ].

  13. PDF DEFINING THE CASE STUDY

    1. question: case studies most useful for answering how, why. 2. propositions, if any to help problematize your question (e.g., organizations collaborate because they derive mutual benefit). 3. units of analysis (a neighborhood or a small group; a new technology or an innovation process?)

  14. Case Study

    A Case study is: An in-depth research design that primarily uses a qualitative methodology but sometimes includes quantitative methodology. Used to examine an identifiable problem confirmed through research. Used to investigate an individual, group of people, organization, or event. Used to mostly answer "how" and "why" questions.

  15. Case Study

    A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation. It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied.

  16. Adapting and blending grounded theory with case study: a practical

    This article tackles how to adapt grounded theory by blending it with case study techniques. Grounded theory is commended for enabling qualitative researchers to avoid priori assumptions and intensely explore social phenomena leading to enhanced theorization and deepened contextualized understanding. However, it is criticized for generating enormous data that is difficult to manage ...

  17. Case Study Analysis as an Effective Teaching Strategy: Perceptions of

    Review of Literature. As a pedagogical strategy, case studies allow the learner to integrate theory with real-life situations as they devise solutions to the carefully designed scenarios (Farashahi & Tajeddin, 2018; Hermens & Clarke, 2009).Another important known observation is that case-study-based teaching exposes students to different cases, decision contexts and the environment to ...

  18. PDF Applying Theory and Research to Practice

    Case Study . The case study category consists of four discrete assignments: (1) development of case study, (2) case study analysis, (3) case study group project part one (applied research), and (4) case study group project part two (original research). Theoretical Book Read . The syllabus explains, "Approximately a third of the way into the

  19. A process-based approach to cognitive behavioral therapy: A theory

    In this paper, we describe the theory underlying PBT and present a case study for how to apply PBT tools and principles to deliver process-informed and person-centered evidence-based treatment. In addition, we discuss lessons learned from our case and provide suggestions for future considerations when implementing PBT in clinical settings.

  20. Writing a Case Study

    A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with g...

  21. Case Study: Definition, Examples, Types, and How to Write

    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.

  22. Treatment for childhood and adolescent dissociation: A systematic review

    The case studies also utilized psychotherapy in some form, two involving what seemed to be trauma-focused psychodynamic therapy (with emphasis on the therapeutic alliance, affect tolerance and acceptance of the self); however, these case studies did not explicitly state this (Allers et al., 1997; Dell & Eisenhower, 1990).

  23. Wavelet-based information theory in quantitative assessment of AFM

    Results of filtering 2D AFM image of the case study sample when using the biorthogonal wave function (Specifically, in our computation, (bior4.4) has been used for filtering 2D AFM image which is ...

  24. Toward Developing a Framework for Conducting Case Study Research

    Case study research has a level of flexibility that is not readily offered by other qualitative approaches such as grounded theory or phenomenology. Case studies are designed to suit the case and research question and published case studies demonstrate wide diversity in study design (Hyett, Kenny, & Dickson-Swift, 2014).

  25. The Power of Preaching and Deliberative Dialogue to Catalyze ...

    This article explores different ways that preachers and congregations have used the sermon-dialogue-sermon process to address social issues in their churches and engage their local community. I begin with a brief review of the homiletic theory behind the emergence of dialogical preaching, including the ways I have integrated this theory into my own method of the sermon-dialogue-sermon (SDS ...

  26. [2402.07109] B-brane Transport and Grade Restriction Rule for

    Download a PDF of the paper titled B-brane Transport and Grade Restriction Rule for Determinantal Varieties, by Ban Lin and Mauricio Romo

  27. The case study approach

    The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design ...

  28. Abortions by Telemedicine and Mailed Pills Are Safe and Effective

    The study, led by researchers at the University of California, San Francisco, looked at the experience of more than 6,000 patients in the months after the federal government began allowing ...