• Case Interview: A comprehensive guide
  • Pyramid Principle
  • Hypothesis driven structure
  • Fit Interview
  • Consulting math
  • The key to landing your consulting job
  • What is a case interview?
  • What do I need to learn to solve cases?
  • How do I practice for case interviews?
  • Fit interviews
  • Interview day - what to expect, with tips
  • How we can help

1. The key to landing your consulting job.

Case interviews - where you are asked to solve a business case study under scrutiny - are the core of the selection process right across McKinsey, Bain and BCG (the “MBB” firms). This interview format is also used pretty much universally across other high-end consultancies; including LEK, Kearney, Oliver Wyman and the consulting wings of the “Big Four”.

If you want to land a job at any of these firms, you will have to ace multiple case interviews.

It is increasingly likely that you will also have to solve online cases given by chatbots etc. You might need to pass these before making it to interview or be asked to sit them alongside first round interviews.

Importantly, case studies aren’t something you can just wing . Firms explicitly expect you to have thoroughly prepared and many of your competitors on interview day will have been prepping for months.

Don’t worry though - MCC is here to help!

This article will take you through a full overview of everything you’ll need to know to do well, linking to more detailed articles and resources at each stage to let you really drill down into the details.

As well as traditional case interviews, we’ll also attend to the new formats in which cases are being delivered and otherwise make sure you’re up to speed with recent trends in this overall part of consulting recruitment.

Before we can figure out how to prepare for a case interview, though, we will first have to properly understand in detail what exactly you are up against. What format does a standard consulting case interview take? What is expected of you? How will you be assessed?

Let's dive right in and find out!

Professional help

Before going further, if this sounds like a lot to get your head around on your own, don't worry - help is available!

Our Case Academy course gives you everything you need to know to crack cases like a pro:

Case Academy Course

To put what you learn into practice (and secure some savings in the process) you can add mock interview coaching sessions with expereinced MBB consultants:

Coaching options

And, if you just want an experienced consultant to take charge of the whole selection process for you, you can check out our comprehensive mentoring programmes:

Explore mentoring

Now, back to the article!

2. What is a case interview?

Before we can hope to tackle a case interview, we have to understand what one is.

In short, a case interview simulates real consulting work by having you solve a business case study in conversation with your interviewer.

This case study will be a business problem where you have to advise a client - that is, an imaginary business or similar organisation in need of guidance.

You must help this client solve a problem and/or make a decision. This requires you to analyse the information you are given about that client organisation and figure out a final recommendation for what they should do next.

Business problems in general obviously vary in difficulty. Some are quite straightforward and can be addressed with fairly standard solutions. However, consulting firms exist precisely to solve the tough issues that businesses have failed to deal with internally - and so consultants will typically work on complex, idiosyncratic problems requiring novel solutions.

Some examples of case study questions might be:

  • How much would you pay for a banking licence in Ghana?
  • Estimate the potential value of the electric vehicle market in Germany
  • How much gas storage capacity should a UK domestic energy supplier build?

Consulting firms need the brightest minds they can find to put to work on these important, difficult projects. You can expect the case studies you have to solve in interview, then, to echo the unique, complicated problems consultancies deal with every day. As we’ll explain here, this means that you need to be ready to think outside the box to figure out genuinely novel solutions.

2.1. What skills do case interviews assess?

Reliably impressing your interviewers means knowing what they are looking for. This means understanding the skills you are being assessed against in some detail.

Overall, it’s important always to remember that, with case studies, there are no strict right or wrong answers. What really matters is how you think problems through, how confident you are with your conclusions and how quick you are with the back of the envelope arithmetic.

The objective of this kind of interview isn’t to get to one particular solution, but to assess your skillset. This is even true of modern online cases, where sophisticated AI algorithms score how you work as well as the solutions you generate.

If you visit McKinsey , Bain and BCG web pages on case interviews, you will find that the three firms look for very similar traits, and the same will be true of other top consultancies.

Broadly speaking, your interviewer will be evaluating you across five key areas:

2.1.1.One: Probing mind

Showing intellectual curiosity by asking relevant and insightful questions that demonstrate critical thinking and a proactive nature. For instance, if we are told that revenues for a leading supermarket chain have been declining over the last ten years, a successful candidate would ask:

“ We know revenues have declined. This could be due to price or volume. Do we know how they changed over the same period? ”

This is as opposed to a laundry list of questions like:

  • Did customers change their preferences?
  • Which segment has shown the decline in volume?
  • Is there a price war in the industry?

2.1.2. Two: Structure

Structure in this context means structuring a problem. This, in turn, means creating a framework - that is, a series of clear, sequential steps in order to get to a solution.

As with the case interview in general, the focus with case study structures isn’t on reaching a solution, but on how you get there.

This is the trickiest part of the case interview and the single most common reason candidates fail.

We discuss how to properly structure a case in more detail in section three. In terms of what your interviewer is looking for at high level, though, key pieces of your structure should be:

  • Proper understanding of the objective of the case - Ask yourself: "What is the single crucial piece of advice that the client absolutely needs?"
  • Identification of the drivers - Ask yourself: "What are the key forces that play a role in defining the outcome?"

Our Problem Driven Structure method, discussed in section three, bakes this approach in at a fundamental level. This is as opposed to the framework-based approach you will find in older case-solving

Focus on going through memorised sequences of steps too-often means failing to develop a full understanding of the case and the real key drivers.

At this link, we run through a case to illustrate the difference between a standard framework-based approach and our Problem Driven Structure method.

2.1.3. Three: Problem Solving

You’ll be tested on your ability to identify problems and drivers, isolate causes and effects, demonstrate creativity and prioritise issues. In particular, the interviewer will look for the following skills:

  • Prioritisation - Can you distinguish relevant and irrelevant facts?
  • Connecting the dots - Can you connect new facts and evidence to the big picture?
  • Establishing conclusions - Can you establish correct conclusions without rushing to inferences not supported by evidence?

2.1.4. Four: Numerical Agility

In case interviews, you are expected to be quick and confident with both precise and approximated numbers. This translates to:

  • Performing simple calculations quickly - Essential to solve cases quickly and impress clients with quick estimates and preliminary conclusions.
  • Analysing data - Extract data from graphs and charts, elaborate and draw insightful conclusions.
  • Solving business problems - Translate a real world case to a mathematical problem and solve it.

Our article on consulting math is a great resource here, though the extensive math content in our MCC Academy is the best and most comprehensive material available.

2.1.5. Five: Communication

Real consulting work isn’t just about the raw analysis to come up with a recommendation - this then needs to be sold to the client as the right course of action.

Similarly, in a case interview, you must be able to turn your answer into a compelling recommendation. This is just as essential to impressing your interviewer as your structure and analysis.

Consultants already comment on how difficult it is to find candidates with the right communication skills. Add to this the current direction of travel, where AI will be able to automate more and more of the routine analytic side of consulting, and communication becomes a bigger and bigger part of what consultants are being paid for.

So, how do you make sure that your recommendations are relevant, smart, and engaging? The answer is to master what is known as CEO-level communication .

This art of speaking like a CEO can be quite challenging, as it often involves presenting information in effectively the opposite way to how you might normally.

To get it right, there are three key areas to focus on in your communications:

  • Top down : A CEO wants to hear the key message first. They will only ask for more details if they think that will actually be useful. Always consider what is absolutely critical for the CEO to know, and start with that. You can read more in our article on the Pyramid Principle .
  • Concise : This is not the time for "boiling the ocean" or listing an endless number possible solutions. CEOs, and thus consultants, want a structured, quick and concise recommendation for their business problem, that they can implement immediately.
  • Fact-based : Consultants share CEOs' hatred of opinions based on gut feel rather than facts. They want recommendations based on facts to make sure they are actually in control. Always go on to back up your conclusions with the relevant facts.

For more detail on all this, check out our full article on delivering recommendations .

Prep the right way

2.2. where are case interviews in the consulting selection process.

Not everyone who applies to a consulting firm will have a case interview - far from it!

In fact, case interviews are pretty expensive and inconvenient for firms to host, requiring them to take consultants off active projects and even fly them back to the office from location for in-person interviews. Ideally, firms want to cut costs and save time by narrowing down the candidate pool as much as possible before any live interviews.

As such, there are some hoops to jump through before you make it to interview rounds.

Firms will typically eliminate as much as 80% of the applicant pool before interviews start. For most firms, 50%+ of applicants might be cut based on resumes, before a similar cut is made on those remaining based on aptitude tests. McKinsey currently gives their Solve assessment to most applicants, but will use their resulting test scores alongside resumes to cut 70%+ of the candidate pool before interviews.

You'll need to be on top of your game to get as far as an interview with a top firm. Getting through the resume screen and any aptitude tests is an achievement in itself!

For readers not yet embroiled in the selection process themselves, let’s put case interviews in context and take a quick look at each stage in turn. Importantly, note that you might also be asked to solve case studies outside interviews as well…

2.2.1. Application screen

It’s sometimes easy to forget that such a large cut is made at the application stage. At larger firms, this will mean your resume and cover letter is looked at by some combination of AI tools, recruitment staff and junior consulting staff (often someone from your own university).

Only the best applications will be passed to later stages, so make sure to check out our free resume and cover letter guides, and potentially get help with editing , to give yourself the best chance possible.

2.2.2. Aptitude tests and online cases

This part of the selection process has been changing quickly in recent years and is increasingly beginning to blur into the traditionally separate case interview rounds.

In the past, GMAT or PST style tests were the norm. Firms then used increasingly sophisticated and often gamified aptitude tests, like the Pymetrics test currently used by several firms, including BCG and Bain, and the original version of McKinsey’s Solve assessment (then branded as the Problem Solving Game).

Now, though, there is a move towards delivering relatively sophisticated case studies online. For example, McKinsey has replaced half the old Solve assessment with an online case. BCG’s Casey chatbot case now directly replaces a live first round case interview, and in the new era of AI chatbots, we expect these online cases to quickly become more realistic and increasingly start to relieve firms of some of the costs of live interviews.

Our consultants collectively reckon that, over time, 50% of case interviews are likely to be replaced with these kinds of cases. We give some specific advice for online cases in section four. However, the important thing to note is that these are still just simulations of traditional case interviews - you still need to learn how to solve cases in precisely the same way, and your prep will largely remain the same.

2.2.3. Rounds of Interviews

Now, let’s not go overboard with talk of AI. Even in the long term, the client facing nature of consulting means that firms will have live case interviews for as long as they are hiring anyone. And in the immediate term, case interviews are still absolutely the core of consulting selection.

Before landing an offer at McKinsey, Bain, BCG or any similar firm, you won’t just have one case interview, but will have to complete four to six case interviews, usually divided into two rounds, with each interview lasting approximately 50-60 minutes .

Being invited to first round usually means two or three case interviews. As noted above, you might also be asked to complete an online case or similar alongside your first round interviews.

If you ace first round, you will be invited to second round to face the same again, but more gruelling. Only then - after up to six case interviews in total, can you hope to receive an offer.

2.3. Typical case interview format

Before we dive in to the nuts and bolts of case cracking, we should give you a bit more detail on what exactly you’ll be up against on interview day.

Case interviews come in very similar formats across the various consultancies where they are used.

The standard case interview can be thought of as splitting into two standalone sub-interviews. Thus “case interviews” can be divided into the case study itself and a “fit interview” section, where culture fit questions are asked.

This can lead to a bit of confusion, as the actual case interview component might take up as little as half of your scheduled “case interview”. You need to make sure you are ready for both aspects.

To illustrate, here is the typical case interview timeline:

  • First 15-30 minutes: Fit Interview - with questions assessing your motivation to be a consultant in that specific firm and your traits around leadership and teamwork. Learn more about the fit interview in our in-depth article here .
  • Next 30-40 minutes: Case Interview - solving a case study
  • Last 5 minutes: Fit Interview again - this time focussing on your questions for your interviewer.

Both the Case and Fit interviews play crucial roles in the finial hiring decision. There is no “average” taken between case and fit interviews: if your performance is not up to scratch in either of the two, you will not be able to move on to the next interview round or get an offer.

NB: No case without fit

Note that, even if you have only been told you are having a case interview or otherwise are just doing a case study, always be prepared to answer fit questions. At most firms, it is standard practice to include some fit questions in all case interviews, even if there are also separate explicit fit interviews, and interviewers will almost invariably include some of these questions around your case. This is perfectly natural - imagine how odd and artificial it would be to show up to an interview, simply do a case and leave again, without talking about anything else with the interviewer before or after.

2.4. Differences between first and second round interviews

Despite interviews in the first and second round following the same format, second/final round interviews will be significantly more intense. The seniority of the interviewer, time pressure (with up to three interviews back-to-back), and the sheer value of the job at stake will likely make a second round consulting case interview one of the most challenging moments of your professional life.

There are three key differences between the two rounds:

  • Time Pressure : Final round case interviews test your ability to perform under pressure, with as many as three interviews in a row and often only very small breaks between them.
  • Focus : Since second round interviewers tend to be more senior (usually partners with 12+ years experience) and will be more interested in your personality and ability to handle challenges independently. Some partners will drill down into your experiences and achievements to the extreme. They want to understand how you react to challenges and your ability to identify and learn from past mistakes.
  • Psychological Pressure: While case interviews in the first round are usually more focused on you simply cracking the case, second round interviewers often employ a "bad cop" strategy to test the way you react to challenges and uncertainty.

2.5. Differences between firms

For the most part, a case interview is a case interview. However, firms will have some differences in the particular ways they like to do things in terms of both the case study and the fit component.

As we’ll see, these differences aren’t hugely impactful in terms of how you prepare. That said, it's always good to know as much as possible about what you will be going up against.

2.5.1. Candidate led vs interviewer led case formats

Most consulting case interview questions test your ability to crack a broad problem, with a case prompt often going something like:

" How much would you pay to secure the rights to run a restaurant in the British Museum? "

You, as a candidate, are then expected to identify your path to solve the case (that is, provide a structure), leveraging your interviewer to collect the data and test your assumptions.

This is known as a “candidate-led” case interview and is used by Bain, BCG and other firms.

However, a McKinsey case interview - especially in the first round - is slightly different, with the interviewer controlling the pace and direction of the conversation much more than with other case interviews.

At McKinsey, your interviewer will ask you a set of pre-determined questions, regardless of your initial structure. For each question, you will have to understand the problem, come up with a mini structure, ask for additional data (if necessary) and come to the conclusion that answers the question.

McKinsey’s cases are thus referred to as “interviewer-led”. This more structured format of case also shows up in online cases by other firms - notably including BCG’s Casey chatbot (with the amusing result that practising McKinsey-style cases can be a great addition when prepping for BCG).

Essentially, these interviewer-led case studies are large cases made up of lots of mini-cases. You still use basically the same method as you would for standard (or candidate-led) cases - the main difference is simply that, instead of using that method to solve one big case, you are solving several mini-cases sequentially.

2.5.2. The McKinsey PEI

McKinsey brands its fit aspect of interviews as the Personal Experience Interview or PEI. Despite the different name, this is really much the same interview you will be going up against in Bain, BCG and any similar firms.

McKinsey does have a reputation for pushing candidates a little harder with fit or PEI questions, focusing on one story per interview and drilling down further into the specific details each time. We discuss this tendency more in our fit interview article. However, no top end firm is going to go easy on you and you should absolutely be ready for the same level of grilling at Bain, BCG and others. Thus any difference isn’t hugely salient in terms of prep.

2.6. How are things changing in 2023?

For the foreseeable future, you are going to have to go through multiple live case interviews to secure any decent consulting job. These might increasingly happen via Zoom rather than in person, but they should remain largely the same otherwise.

However, things are changing and the rise of AI in recent months seems pretty much guaranteed to accelerate existing trends.

Even before the explosive development of AI chatbots like ChatGPT we have seen in recent months, automation was already starting to change the recruitment process.

As we mentioned, case interviews are expensive and inconvenient for firms to run. Ideally, then, firms will try to reduce the number of interviews required for recruitment as far as possible. For many years, tests of various kinds served to cut down the applicant pool and thus the number of interviews. However, these tests had a limited capacity to assess candidates against the full consulting skillset in the way that case interviews do so well.

More recently, though, the development of online testing has allowed for more and more advanced assessments. Top consulting firms have been leveraging screening tests that better and better capture the same skillset as case interviews. Eventually this is converging on automated case studies. We see this very clearly with the addition of the Redrock case to McKinsey’s Solve assessment.

As these digital cases become closer to the real thing, the line between test and interview blurs. Online cases don’t just reduce the number of candidates to interview, but start directly replacing interviews.

Case in point here is BCG’s Casey chatbot . Previously, BCG had deployed less advanced online cases and similar tests to weed out some candidates before live case interviews began. Now, though, Casey actually replaces one first round case interview.

Casey, at time of writing, is still a relatively “dumb” chatbot, basically running through a pre-set script. The Whatsapp-like interface does a lot of work to make it feel like one is chatting to a “real person” - the chatbot itself, though, cannot provide feedback or nudges to candidates as would a human interviewer.

We fully expect that, as soon as BCG and other firms can train a truer AI, these online cases will become more widespread and start replacing more live interviews.

We discuss the likely impacts of advanced AI on consulting recruitment and the industry more broadly in our blog.

Here, though, the real message is that you should expect to run into digital cases as well as traditional case interviews.

Luckily, despite any changes in specific format, you will still need to master the same fundamental skills and prepare in much the same way.

We’ll cover a few ways to help prepare for chatbot cases in section four. Ultimately, though, firms are looking for the same problem solving ability and mindset as a real interviewer. Especially as chatbots get better at mimicking a real interviewer, candidates who are well prepared for case cracking in general should have no problem with AI administered cases.

2.6.1. Automated fit interviews

Analogous to online cases, in recent years there has been a trend towards automated, “one way” fit interviews, with these typically being administered for consultancies by specialist contractors like HireVue or SparkHire.

These are kind of like Zoom interviews, but if the interviewer didn’t show up. Instead you will be given fit questions to answer and must record your answer in your computer webcam. Your response will then go on to be assessed by an algorithm, scoring both what you say and how you say it.

Again, with advances in AI, it is easy to imagine these automated interviews going from fully scripted interactions, where all candidates are asked the same list of questions, to a more interactive experience. Thus, we might soon arrive at a point where you are being grilled on the details of your stories - McKinsey PEI style - but by a bot rather than a human.

We include some tips on this kind of “one way” fit interview in section six here.

3. What do I need to learn to solve cases?

If you’re new to case cracking. You might feel a bit hopeless when you see a difficult case question, not having any idea where to start.

In fact though, cracking cases is much like playing chess. The rules you need to know to get started are actually pretty simple. What will make you really proficient is time and practice.

In this section, we’ll run through a high level overview of everything you need to know, linking to more detailed resources at every step.

3.1. Business fundamentals

Obviously, you are going to need to be familiar with basic business concepts in order to understand the case studies you are given in the first instance.

If you are coming from a business undergrad, an MBA or are an experienced hire, you might well have this covered already.

However, many consultants will be entering from engineering or similar backgrounds and the major consulting firms are hiring more and more PhDs and non-MBA master's graduates from all subjects. These individuals will need to get up to speed on business fundamentals.

Luckily, you don’t need a degree-level understanding of business to crack interview cases, and a lot of the information you will pick up by osmosis as you read through articles like this and go through cases.

However, some things you will just need to sit down and learn. We cover everything you need to know in some detail in our Case Academy course. However, some examples here of things you need to learn are:

  • Basic accounting (particularly how to understand all the elements of a balance sheet)
  • Basic economics
  • Basic marketing
  • Basic strategy

Note, though, that learning the very basics of business is the beginning rather than the end of your journey.

Once you are able to “speak business” at a rudimentary level, you should try to “become fluent” and immerse yourself in reading/viewing/listening to as wide a variety of business material as possible, getting a feel for all kinds of companies and industries - and especially the kinds of problems that can come up in each context and how they are solved.

The material put out by the consulting firms themselves is a great place to start, but you should also follow the business news and find out about different companies and sectors as much as possible between now and interviews. Remember, if you’re going to be a consultant, this should be fun rather than a chore!

3.2. How to solve cases like a real consultant

This is the really important bit.

If you look around online for material on how to solve case studies, a lot of what you find will set out framework-based approaches. However, as we have mentioned, these frameworks tend to break down with more complex, unique cases - with these being exactly the kind of tough case studies you can expect to be given in your interviews.

To address this problem, the MyConsultingCoach team has developed a new, proprietary approach to case cracking that replicates how top management consultants approach actual engagements.

MyConsultingCoach’s Problem Driven Structure approach is a universal problem solving method that can be applied to any business problem , irrespective of its nature.

As opposed to just selecting a generic framework for each case, the Problem Driven Structure approach works by generating a bespoke structure for each individual question and is a simplified version of the roadmap McKinsey consultants use when working on engagements.

The canonical seven steps from McKinsey on real projects are simplified to four for case interview questions, as the analysis required for a six-month engagement is somewhat less than that needed for a 45-minute case study. However, the underlying flow is the same.

This video has more information on how frameworks can be unreliable and how we address this problem:

Otherwise, let's zoom in to see how our method actually works in more detail:

3.2.1. Identify the problem

Identifying the problem means properly understanding the prompt/question you are given, so you get to the actual point of the case.

This might sound simple, but cases are often very tricky, and many candidates irretrievably mess things up within the first few minutes of starting. Often, they won’t notice this has happened until they are getting to the end of their analysis. Then, they suddenly realise that they have misunderstood the case prompt - and have effectively been answering the wrong question all along!

With no time to go back and start again, there is nothing to do. Even if there were time, making such a silly mistake early on will make a terrible impression on their interviewer, who might well have written them off already. The interview is scuppered and all the candidate’s preparation has been for nothing.

This error is so galling as it is so readily avoidable.

Our method prevents this problem by placing huge emphasis on a full understanding of the case prompt. This lays the foundations for success as, once we have identified the fundamental, underlying problem our client is facing, we focus our whole analysis around finding solutions to this specific issue.

Now, some case interview prompts are easy to digest. For example, “Our client, a supermarket, has seen a decline in profits. How can we bring them up?”. However, many of the prompts given in interviews for top firms are much more difficult and might refer to unfamiliar business areas or industries. For example, “How much would you pay for a banking license in Ghana?” or “What would be your key areas of concern be when setting up an NGO?”

Don’t worry if you have no idea how you might go about tackling some of these prompts!

In our article on identifying the problem and in our full lesson on the subject in our MCC Academy course, we teach a systematic, four step approach to identifying the problem , as well as running through common errors to ensure you start off on the right foot every time!

This is summarised here:

Four Steps to Identify the Problem

Following this method lets you excel where your competitors mess up and get off to a great start in impressing your interviewer!

3.2.2. Build your problem driven structure

After you have properly understood the problem, the next step is to successfully crack a case is to draw up a bespoke structure that captures all the unique features of the case.

This is what will guide your analysis through the rest of the case study and is precisely the same method used by real consultants working on real engagements.

Of course, it might be easier here to simply roll out one an old-fashioned framework, and a lot of candidates will do so. This is likely to be faster at this stage and requires a lot less thought than our problem-driven structure approach.

However, whilst our problem driven structure approach requires more work from you, our method has the advantage of actually working in the kind of complex case studies where generic frameworks fail - that is exactly the kind of cases you can expect at an MBB interview .

Since we effectively start from first principles every time, we can tackle any case with the same overarching method. Simple or complex, every case is the same to you and you don’t have to gamble a job on whether a framework will actually work

In practice, structuring a problem with our method means drawing up either an issue tree or an hypothesis tree , depending on how you are trying to address the problem.

These trees break down the overall problem into a set of smaller problems that you can then solve individually. Representing this on a diagram also makes it easy for both you and your interviewer to keep track of your analysis.

To see how this is done, let’s look at the issue tree below breaking down the revenues of an airline:

Frame the Airline Case Study

These revenues can be segmented as the number of customers multiplied by the average ticket price. The number of customers can be further broken down into a number of flights multiplied by the number of seats, times average occupancy rate. The node corresponding to the average ticket price can then be segmented further.

It is worth noting that the same problem can be structured in multiple valid ways by choosing different means to segment the key issues.

That said, not all valid structures are equally useful in solving the underlying problem. A good structure fulfils several requirements - including MECE-ness , level consistency, materiality, simplicity, and actionability. It’s important to put in the time to master segmentation, so you can choose a scheme isn’t only valid, but actually useful in addressing the problem.

After taking the effort to identify the problem properly, an advantage of our method is that it will help ensure you stay focused on that same fundamental problem throughout. This might not sound like much, but many candidates end up getting lost in their own analysis, veering off on huge tangents and returning with an answer to a question they weren’t asked.

Another frequent issue - particularly with certain frameworks - is that candidates finish their analysis and, even if they have successfully stuck to the initial question, they have not actually reached a definite solution. Instead, they might simply have generated a laundry list of pros and cons, with no clear single recommendation for action.

Clients employ consultants for actionable answers, and this is what is expected in the case interview. The problem driven structure excels in ensuring that everything you do is clearly related back to the key question in a way that will generate a definitive answer. Thus, the problem driven structure builds in the hypothesis driven approach so characteristic of real consulting practice.

You can learn how to set out your own problem driven structures in our article here and in our full lesson in the MCC Academy course.

Join thousands of other candidates cracking cases like pros

3.2.3. lead the analysis.

A problem driven structure might ensure we reach a proper solution eventually, but how do we actually get there?

We call this step " leading the analysis ", and it is the process whereby you systematically navigate through your structure, identifying the key factors driving the issue you are addressing.

Generally, this will mean continuing to grow your tree diagram, further segmenting what you identify as the most salient end nodes and thus drilling down into the most crucial factors causing the client’s central problem.

Once you have gotten right down into the detail of what is actually causing the company’s issues, solutions can then be generated quite straightforwardly.

To see this process in action, we can return to our airline revenue example:

Lead the analysis for the Airline Case Study

Let’s say we discover the average ticket price to be a key issue in the airline’s problems. Looking closer at the drivers of average ticket price, we find that the problem lies with economy class ticket prices. We can then further segment that price into the base fare and additional items such as food.

Having broken down the issue to such a fine-grained level, solutions occur quite naturally. In this case, we can suggest incentivising the crew to increase onboard sales, improving assortment in the plane, or offering discounts for online purchases.

Our article on leading the analysis is a great primer on the subject, with our video lesson in the MCC Academy providing the most comprehensive guide available.

3.2.4. Provide recommendations

So you have a solution - but you aren’t finished yet!

Now, you need to deliver your solution as a final recommendation.

This should be done as if you are briefing a busy CEO and thus should be a one minute, top-down, concise, structured, clear, and fact-based account of your findings.

The brevity of the final recommendation belies its importance. In real life consulting, the recommendation is what the client has potentially paid millions for - from their point of view, it is the only thing that matters.

In an interview, your performance in this final summing up of your case is going to significantly colour your interviewer’s parting impression of you - and thus your chances of getting hired!

So, how do we do it right?

Barbara Minto's Pyramid Principle elegantly sums up almost everything required for a perfect recommendation. The answer comes first , as this is what is most important. This is then supported by a few key arguments , which are in turn buttressed by supporting facts .

Across the whole recommendation, the goal isn’t to just summarise what you have done. Instead, you are aiming to synthesize your findings to extract the key "so what?" insight that is useful to the client going forward.

All this might seem like common sense, but it is actually the opposite of how we relay results in academia and other fields. There, we typically move from data, through arguments and eventually to conclusions. As such, making good recommendations is a skill that takes practice to master.

We can see the Pyramid Principle illustrated in the diagram below:

The Pyramid principle often used in consulting

To supplement the basic Pyramid Principle scheme, we suggest candidates add a few brief remarks on potential risks and suggested next steps . This helps demonstrate the ability for critical self-reflection and lets your interviewer see you going the extra mile.

The combination of logical rigour and communication skills that is so definitive of consulting is particularly on display in the final recommendation.

Despite it only lasting 60 seconds, you will need to leverage a full set of key consulting skills to deliver a really excellent recommendation and leave your interviewer with a good final impression of your case solving abilities.

Our specific article on final recommendations and the specific video lesson on the same topic within our MCC Academy are great, comprehensive resources. Beyond those, our lesson on consulting thinking and our articles on MECE and the Pyramid Principle are also very useful.

3.3. Common case types and the building blocks to solve them

You should tackle each new case on its own merits. However, that’s not to say there aren’t recurring themes that come up fairly reliably in cases - there absolutely are. Business is business and case studies will often feature issues like profitability, competition etc.

Old fashioned framework approaches would have you simply select a defined framework for each kind of case and, in effect, just run the algorithm and wait for a solution to fall out.

We’ve already explained how frameworks can let you down. In this context, too many candidates will fall into the trap of selecting a framework for that case type that simply won’t work for their specific case.

The counterpoint in favour of frameworks, though, is that they are at least fast and prevent you having to start from the ground up with a common kind of case.

Ideally, you should have the best of both worlds - and this is why, in our articles on this site and in our MCC Academy course, we have developed a set of “building bocks” for common case themes.

As they name suggests, building blocks give you modular components for different kinds of case to help build out your own custom structures faster. These then allow you to leverage the symmetries between cases without inheriting the inflexibility of frameworks.

Let’s take a look at five different case types and get a brief idea of how our building block approach helps you with each. You can find more detail on each in the full length articles linked, as well as in the full-length video lessons in our MCC Academy course.

3.3.1. Estimation

Consultants need to push forward to provide definitive recommendations to clients in a timely manner despite typically not having access to full information on a problem. Estimation of important quantities is therefore at the heart of real life consulting work.

Estimation is thus just as fundamental to case cracking.

A case interview might centre on an estimation question, and this might be quite common for a first round interview. However, estimation is also very likely to be a crucial part of pretty well any other kind of case question you receive is likely to include estimation as a crucial component of your analysis.

The kinds of estimation you might be asked to make in a case interview can be very daunting:

  • How many bank branches are there in Italy?
  • How many cars are sold in Berlin in one year?
  • How many people will buy the latest high-tech smartphone on the market?

You might have no idea where to begin with these examples. However, tempting as it might be, your answer cannot ever be a simple guess .

A decent estimation does have a guessed element - though this should really be an educated guess based on some pre-existing knowledge. However, this guessed element is always then combined with a rigorous quantitative method to arrive at a reasonable estimation.

In context of a case interview, it’s important to realise that your interviewer doesn’t really care about the right answer (they don’t need to ask you to find out, after all). What’s important is showing the rational process by which you get to your answer.

A guess that was somehow exactly correct is no good compared to a “wrong” answer that was reached by a very sensible, intelligent process of estimation. In cases, this method will often be a matter of segmentation.

So, where would we start in working out how many cars are sold in Berlin, for example?

The key to estimation case questions is the ability to logically break down the problem into more manageable pieces. In consulting case studies, this will generally mean segmenting a wider population to find a particular target group. For example, starting from the total population of Berlin and narrowing down to the cohort of individuals who will buy a car that year.

There are usually many ways to segment the same starting population, and several different segmentation schemes might be equally valid. However, it is crucial to choose the specific method best suited to the goal in answering the question and allowing you to best leverage the data you have available.

Segmentation must be allied with assumptions in order to arrive at an estimation. These assumptions are the “guessed” element of estimations we mentioned above. Assumptions cannot just be plucked from thin air, but must always be reasonable .

The example below showcases both the segmentation and assumptions made in an estimation of the size of the wedding planning market in London:

Estimation Example Structure

Our articles on estimation and the MECE concept are great starting points in getting to grips with consulting estimation. However, the best place to learn how to make estimations is with the dedicated building block video lesson in our MCC Academy course.

Those of you from physics or engineering backgrounds will probably see a lot in common with Fermi questions . We have plenty of estimation cases for you to work through in our free case library. However, Fermi questions are a great way of getting a little extra practice and you can find a lifetime’s supply online.

3.3.2. Profitability

The fundamental goal of any normal business is to maximise profits - nobody is getting up and going to work to lose money. Even Silicon Valley tech start-ups are supposed to be profitable some day!

Profitability problems are thus bread and butter issues for management consultants.

Clients often tell consultants broadly the same story. The business was doing in well in recent years, with strong profits. However, some recent turn of events has upset the status quo and led to concerns around profit levels. Consultants are brought in as businesses are often sufficiently complex that it can be difficult to figure out precisely where and why the company is losing money - let alone how to then reverse the situation and restore healthy profits.

Despite steady growth in customer flow, the Walfort supermarket chain has seen falling profits in the past year. What is the reason for this decline?

Understanding profitability ultimately means understanding the various components that determine a company’s profit. You will need to learn to decompose profit first into revenues and costs (profit being the synthesis of these two factors). Crucially, you then need to segment further, distinguishing different specific revenue streams and separating various fixed and variable costs.

To take an example, just examining the revenue side of profit, the incoming revenues for an insurance firm might be broken down as follows:

Insurance Revenues

Improving profitability will inherently mean increasing revenues and/or decreasing costs. To solve profitability problems, we thus have to understand the ways we can minimise different costs, as well as ways to drive sales and/or optimise pricing to increase revenue. Importantly, you must be able to judge which of these options is best suited to address specific scenarios.

The key to tackling the complex kind of profitability questions given by MBB-level consultancies lies in this proper segmentation.

By contrast, old-fashioned case interview frameworks will simply have you look at aggregate cost and revenue data before recommending generic cost-cutting or revenue-driving measures. However, this will often lead to negative outcomes in more involved cases, making matters worse for the client.

For example, it might well be that a company actually makes a loss when it serves a certain cohort of customers. An airline, for instance, might lose money on economy class customers but make a healthy profit on each business class customer. Attempts to boost revenue by increasing sales across the board might actually reduce profit further by increasing the number of economy class customers. What is required is targeted measures to increase focus on business class and/or mitigate economy class losses.

You can start learning to segment these kinds of cases properly in our article on profitability , whilst the best way to really master profitability questions is our full lesson on the subject in the Building Blocks section of our MCC Academy course.

3.3.3. Pricing

For a company to be profitable at all, it is a pre-requisite that it charges the right price for whatever it sells. However, establishing what price to charge for any one product - or indeed a whole suite of related products - can be a highly complex business.

Consultants are often engaged to negotiate the many variables, with all their complex interdependencies, at play in pricing. Correspondingly, then, pricing is a common theme in case interviews.

  • A company launches a new smartphone with a significantly improved camera. How much should they charge?
  • A doughnut chain wants to start selling coffee in their shops. How much should they charge per cup?

Clearly, lot of different factors can influence the answers to these questions, and it can be difficult to know where to start. To get a handle on all this complexity, you will need to take a methodical, structured approach.

To really understand pricing, you must begin from fundamentals like the customer’s willingness to pay, the value captured by the company, and the value created for the customer. These basics are shown in the diagram below:

Pricing Basics

This might seem simple enough, but the exact level at which prices are ultimately set is determined by a whole host of factors, including product availability, market trends, and the need to maintain a competitive position within the market. In particular, if we are changing the price of an existing product, we must consider how the price elasticity of demand might cause sales to fluctuate.

Our four-step method for pricing starts from establishing the customer’s next best alternative, calculating the value added by our own product, and working from there. A summary of this method is given, along with an overview of pricing in general, in our article on the subject . However, the most complete resource is our pricing lesson in the MCC Academy .

3.3.4. Valuation

Valuation is fundamental to any kind of investment. Before allocating capital towards a particular opportunity, an investor must understand precisely what value it holds and how this compares to the other available options.

In short, valuation tells us how much we should be willing to pay to acquire a company or an asset.

There are many ways to value an asset - indeed the finer points are still subject to research in both the academic and private sectors.

Standard ways to assign value include asset-based valuations (notably the Net Asset Value or NAV) and the various multiples so widely used by market traders.

However, in consulting case interviews, you will only usually need to be familiar with Net Present Value (NPV) . This means you need to learn and master the NPV equation:

NPV Equation

CF = Cash Flow r = Discount Rate

Whilst this is a pretty simple equation on the face of it, in order to make proper use of it, you will also need to develop a feel for interest/discount rates appropriate to different cases. This will be essential, as you will often have to estimate rational values for these rates for different investments before plugging those values into the NPV equation. Our Case Academy course has more detail here.

Note, though, that NPV is only really half the story.

NPV provides a kind of “absolute” value for an asset. However, the fact is that the worth of any asset will be different for different buyers , depending largely upon what the buyer already owns. In just the same way a spare clutch for a 1975 Ford will be a lot less valuable to a cyclist than to someone restoring the relevant classic car, so a courier business will be more valuable to an online retailer than to an airline.

As such, what we call the Total Enterprise Value (TEV) of an asset is calculated as a function of that asset’s NPV and of the potential cost and revenue synergies resulting from an acquisition. This is shown in the useful structure below:

TEV

You can learn more about all aspects of valuation in our article here , as well as in our dedicated video lesson in MCC Academy . These include guides to the kind of interest rates typically required to finance different kinds of investment.

3.3.5. Competitive Interactions

Most of what we’ve discussed so far in terms of case themes and our building block approach to them will all depend upon the prevailing competitive landscape our client exists within. Product prices, profit levels and ultimately valuations can all change over time in response to competition.

What is more, the zero sum dynamics of competitive interactions mean that these things can change quickly .

Companies enjoying near monopolies for years or even decades can quickly see their values go to zero, or near enough, in the face of some innovation by a competitor coming onto the market.

Nokia and Kodak thoroughly dominated the mobile phone and photography markets respectively - until new companies with new products pulled the rug out from under them and led to precipitous collapses.

New market entrants or old competitors with new ideas can throw a company’s whole business model up in the air overnight . Complex decisions about profound changes need to be made yesterday. Firms trying to save themselves will often slash prices in attempts to maintain sales - though this can actually make things worse and result in a corporate death-spiral. Consultants are then frequently called in to help companies survive - with this type of engagement carrying over to inform case interview questions.

You are running an airline and a low-cost competitor, like Ryanair, decides to start operating on your routes. You are rapidly losing customers to their lower fares. How do you respond?

Your eventual solutions to competitive interaction problems will likely need to be novel and unique to the situation. However, the process by which we understand competitive interactions and move towards those solutions is usually very methodical, moving through the limited dimensions in which a company can take action.

The following structure neatly encodes the general options open to responding to new sources of competition:

Competitive Interaction Structure

Of course, we would never suggest that you blanket-apply any strict, inflexible methodology to a whole swathe of case questions – this is precisely the approach that causes so much trouble for candidates using old-fashioned frameworks.

This structure is only a starting point - a shortcut to a bespoke framework specific to the case question in hand. You might well have to alter the details of the structure shown and you will almost certainly have to expand it as you lead the analysis . How you build out your structure and the solutions you provide are necessarily going to depend upon the specific details of the case question.

Thus, in order to deal with competitive interactions, you will need to put in the time to understand how the different strategies available function - as well as how competitors might then react to implementing such strategies. With enough practice, though, soon you won’t be fazed by even the most complex cases of competition between firms.

You can learn more in our article here and in our dedicated video lesson on competitive interaction in the MCC Academy case interview course.

3.4. Mental mathematics

Almost every interview case study will feature some mental mathematics and this is an area where many many candidates let themselves down.

As such, it makes sense to out in the time and make sure you are fully proficient.

Nothing beyond high school level is required, but you probably don’t do much mental arithmetic day to day and will likely need to practice quite a lot to get good enough to reliably perform at pace, under pressure.

We give a high-level overview of what you need to know in our consulting math article , but devote a whole section of our MCC Academy course to a deep dive on consulting math, with plenty of practice material to get you up to scratch.

4. How do I practice for case interviews?

As we said above - case interviews are much like chess. The rules are relatively quick to learn, but you need to practice a lot to get good.

If you’re working through our MCC Academy course, we recommend getting through the core Problem Driven Structure section. After that, you should be practising alongside working through the remainder of the course and beyond. However you do things, you need to get up to speed with the fundamentals before practice is going to do much more than confuse you.

Of course, if you’re enrolled in one of our mentoring programmes , your mentor will let you know precisely when and how you should be scheduling practice, as well as tracking your progress throughout.

4.1. Solo Practice

For solitary preparation, one of the best uses of your time is to work on your mental mathematics . This skill is neglected by many applicants - much to their immediate regret in the case interview. Find our mental math tool here or in our course, and practice at least ten minutes per day, from day one until the day before the interview.

Once you've covered our Building Blocks section, you should then start working through the cases in My Consulting Coach's case bank alongside your work on the course. This is a large library of case interview questions and answers in different formats and difficulties.

To build your confidence, start out on easier case questions, work through with the solutions, and don't worry about time. As you get better, you can move on to more difficult cases and try to get through them more quickly. You should practice around eight case studies on your own to build your confidence.

4.2. Peer practice

One you have worked through eight cases solo, you should be ready to simulate the interview more closely and start working with another person.

Here, many candidates turn to peer practice - that is, doing mock case interviews with friends, classmates or others also applying to consulting.

If you’re in university, and especially in business school, there will very likely be a consulting club for you to join and do lots of case practice with. If you don’t have anyone to practice, though, or if you just want to get a bit more volume in with others, our free meeting board lets you find fellow applicants from around the world with whom to practice.

4.3. Professional practice

You can do a lot practising by yourself and with peers. However, nothing will bring up your skills so quickly and profoundly as working with a real consultant.

Perhaps think about it like boxing. You can practice drills and work on punch bags all you want, but at some point you need to get into the ring and do some actual sparring if you ever want to be ready to fight.

Of course, it isn’t possible to secure the time of experienced top-tier consultants for free. However, when considering whether you should invest to boost your chances of success, it is worth considering the difference in your salary over even a just few years between getting into a top-tier firm versus a second-tier one. In the light of thousands in increased annual earnings (easily accumulating into millions over multiple years), it becomes clear that getting expert interview help really is one of the best investments you can make in your own future.

Should you decide to make this step, MyConsultingCoach can help, offering the highest quality case interview coaching service available . Each MCC case coach is selected as an MBB consultant with two or more years of experience and strong coaching expertise.

Case interview coaching is hugely beneficial in itself. However, for those who want to genuinely maximise their chances of securing a job offer - and especially for time-poor, busy professionals or hard-pressed students who want to take the guesswork and wasted time out of their case interview prep - we also offer a much more comprehensive service .

With one of our bespoke mentoring programmes , you are paired with a 5+ year experienced, ex-MBB mentor of your choosing, who will then oversee your whole case interview preparation from start to finish - giving you your best possible chance of landing a job!

4.4. Practice for online cases

Standard preparation for interview case studies will carry directly over to online cases.

However, if you want to do some more specific prep, you can work through cases solo to a timer and using a calculator and/or Excel (online cases generally allow calculators and second computers to help you, whilst these are banned in live case interviews).

Older PST-style questions also make great prep, but a particularly good simulation is the self-assessment tests included in our Case Academy course . These multiple choice business questions conducted with a strict time limit are great preparation for the current crop of online cases.

5. Fit interviews

As we’ve noted, even something billed as a case interview is very likely to contain a fit interview as a subset.

We have an article on fit interviews and also include a full set of lessons on how to answer fit questions properly as a subset of our comprehensive Case Academy course .

Here though, the important thing to convey is that you take preparing for fit questions every bit as seriously as you do case prep.

Since they sound the same as you might encounter when interviewing for other industries, the temptation is to regard these as “just normal interview questions”.

However, consulting firms take your answers to these questions a good deal more seriously than elsewhere.

This isn’t just for fluffy “corporate culture” reasons. The long hours and close teamwork, as well as the client-facing nature of management consulting, mean that your personality and ability to get on with others is going to be a big part of making you a tolerable and effective co-worker.

If you know you’ll have to spend 14+ hour working days with someone you hire and that your annual bonus depends on them not alienating clients, you better believe you’ll pay attention to their character in interview.

There are also hard-nosed financial reasons for the likes of McKinsey, Bain and BCG to drill down so hard on your answers.

In particular, top consultancies have huge issues with staff retention. The average management consultant only stays with these firms for around two years before they have moved on to a new industry.

In some cases, consultants bail out because they can’t keep up with the arduous consulting lifestyle of long hours and endless travel. In many instances, though, departing consultants are lured away by exit opportunities - such as the well trodden paths towards internal strategy roles, private equity or becoming a start-up founder.

Indeed, many individuals will intentionally use a two year stint in consulting as something like an MBA they are getting paid for - giving them accelerated exposure to the business world and letting them pivot into something new.

Consulting firms want to get a decent return on investment for training new recruits. Thus, they want hires who not only intend to stick with consulting longer-term, but also have a temperament that makes this feasible and an overall career trajectory where it just makes sense for them to stay put.

This should hammer home the point that, if you want to get an offer, you need to be fully prepared to answer fit questions - and to do so excellently - any time you have a case interview.

6. Interview day - what to expect, with tips

Of course, all this theory is well and good, but a lot of readers might be concerned about what exactly to expect in real life . It’s perfectly reasonable to want to get as clear a picture as possible here - we all want to know what we are going up against when we face a new challenge!

Indeed, it is important to think about your interview in more holistic terms, rather than just focusing on small aspects of analysis. Getting everything exactly correct is less important than the overall approach you take to reasoning and how you communicate - and candidates often lose sight of this fact.

In this section, then, we’ll run through the case interview experience from start to finish, directing you to resources with more details where appropriate. As a supplement to this, the following video from Bain is excellent. It portrays an abridged version of a case interview, but is very useful as a guide to what to expect - not just from Bain, but from McKinsey, BCG and any other high-level consulting firm.

6.1. Getting started

Though you might be shown through to the office by a staff member, usually your interviewer will come and collect you from a waiting area. Either way, when you first encounter them, you should greet your interviewer with a warm smile and a handshake (unless they do not offer their hand). Be confident without verging into arrogance. You will be asked to take a seat in the interviewer’s office, where the interview can then begin.

6.1.1. First impressions

In reality, your assessment begins before you even sit down at your interviewer’s desk. Whether at a conscious level or not, the impression you make within the first few seconds of meeting your interviewer is likely to significantly inform the final hiring decision (again, whether consciously or not).

Your presentation and how you hold yourself and behave are all important. If this seems strange, consider that, if hired, you will be personally responsible for many clients’ impressions of the firm. These things are part of the job! Much of material on the fit interview is useful here, whilst we also cover first impressions and presentation generally in our article on what to wear to interview .

As we have noted above, your interview might start with a fit segment - that is, with the interviewer asking questions about your experiences, your soft skills, and motivation to want to join consulting generally and that firm in particular. In short, the kinds of things a case study can’t tell them about you. We have a fit interview article and course to get you up to speed here.

6.1.2. Down to business

Following an initial conversation, your interviewer will introduce your case study , providing a prompt for the question you have to answer. You will have a pen and paper in front of you and should (neatly) note down the salient pieces of information (keep this up throughout the interview).

It is crucial here that you don’t delve into analysis or calculations straight away . Case prompts can be tricky and easy to misunderstand, especially when you are under pressure. Rather, ask any questions you need to fully understand the case question and then validate that understanding with the interviewer before you kick off any analysis. Better to eliminate mistakes now than experience that sinking feeling of realising you have gotten the whole thing wrong halfway through your case!

This process is covered in our article on identifying the problem and in greater detail in our Case Academy lesson on that subject.

6.1.3. Analysis

Once you understand the problem, you should take a few seconds to set your thoughts in order and draw up an initial structure for how you want to proceed. You might benefit from utilising one or more of our building blocks here to make a strong start. Present this to your interviewer and get their approval before you get into the nuts and bolts of analysis.

We cover the mechanics of how to structure your problem and lead the analysis in our articles here and here and more thoroughly in the MCC Case Academy . What it is important to convey here, though, is that your case interview is supposed to be a conversation rather than a written exam . Your interviewer takes a role closer to a co-worker than an invigilator and you should be conversing with them throughout.

Indeed, how you communicate with your interviewer and explain your rationale is a crucial element of how you will be assessed. Case questions in general, are not posed to see if you can produce the correct answer, but rather to see how you think . Your interviewer wants to see you approach the case in a structured, rational fashion. The only way they are going to know your thought processes, though, is if you tell them!

To demonstrate this point, here is another excellent video from Bain, where candidates are compared.

Note that multiple different answers to each question are considered acceptable and that Bain is primarily concerned with the thought processes of the candidate’s exhibit .

Another reason why communication is absolutely essential to case interview success is the simple reason that you will not have all the facts you need to complete your analysis at the outset. Rather, you will usually have to ask the interviewer for additional data throughout the case to allow you to proceed .

NB: Don't be let down by your math!

Your ability to quickly and accurately interpret these charts and other figures under pressure is one of the skills that is being assessed. You will also need to make any calculations with the same speed and accuracy (without a calculator!). As such, be sure that you are up to speed on your consulting math .

6.1.4. Recommendation

Finally, you will be asked to present a recommendation. This should be delivered in a brief, top-down "elevator pitch" format , as if you are speaking to a time-pressured CEO. Again here, how you communicate will be just as important as the details of what you say, and you should aim to speak clearly and with confidence.

For more detail on how to give the perfect recommendation, take a look at our articles on the Pyramid Principle and providing recommendations , as well the relevant lesson within MCC Academy .

6.1.5. Wrapping up

After your case is complete, there might be a few more fit questions - including a chance for you to ask some questions of the interviewer . This is your opportunity to make a good parting impression.

We deal with the details in our fit interview resources. However, it is always worth bearing in mind just how many candidates your interviewers are going to see giving similar answers to the same questions in the same office. A pretty obvious pre-requisite to being considered for a job is that your interviewer remembers you in the first place. Whilst you shouldn't do something stupid just to be noticed, asking interesting parting questions is a good way to be remembered.

Now, with the interview wrapped up, it’s time to shake hands, thank the interviewer for their time and leave the room .

You might have other interviews or tests that day or you might be heading home. Either way, if know that you did all you could to prepare, you can leave content in the knowledge that you have the best possible chance of receiving an email with a job offer. This is our mission at MCC - to provide all the resources you need to realise your full potential and land your dream consulting job!

6.2. Remote and one-way interview tips

Zoom case interviews and “one-way” automated fit interviews are becoming more common as selection processes are increasingly remote, with these new formats being accompanied by their own unique challenges.

Obviously you won’t have to worry about lobbies and shaking hands for a video interview. However, a lot remains the same. You still need to do the same prep in terms of getting good at case cracking and expressing your fit answers. The specific considerations around remote interviews are, in effect, around making sure you come across as effectively as you would in person.

6.2.1. Connection

It sounds trivial, but a successful video interview of any kind presupposes a functioning computer with a stable and sufficient internet connection.

Absolutely don’t forget to have your laptop plugged in, as your battery will definitely let you down mid-interview. Similarly, make sure any housemates or family know not to use the microwave, vacuum cleaner or anything else that makes wifi cut out (or makes a lot of noise, obviously)

If you have to connect on a platform you don’t use much (for example, if it’s on Teams and you’re used to Zoom), make sure you have the up to date version of the app in advance, rather than having to wait for an obligatory download and end up late to join. Whilst you’re at it, make sure you’re familiar with the controls etc. At the risk of being made fun of, don’t be afraid to have a practice call with a friend.

6.2.2. Dress

You might get guidance on a slightly more relaxed dress code for a Zoom interview. However, if in doubt, dress as you would for the real thing (see our article here ).

Either way, always remember that presentation is part of what you are being assessed on - the firm needs to know you can be presentable for clients. Taking this stuff seriously also shows respect for your interviewer and their time in interviewing you.

6.2.3. Lighting

An aspect of presentation that you have to devote some thought to for a Zoom interview is your lighting.

Hopefully, you long ago nailed a lighting set-up during the Covid lockdowns. However, make sure to check your lighting in advance with your webcam - bearing in mind what time if day your interview actually is. If your interview is late afternoon, don’t just check in the morning. Make sure you aren’t going to be blinded from light coming in a window behind your screen, or that you end up with the weird shadow stripes from blinds all over your face.

Natural light is always best, but if there won’t be much of that during your interview, you’ll likely want to experiment with moving some lamps around.

6.2.4. Clarity

The actual stories you tell in an automated “one-way” fit interview will be the same as for a live equivalent. If anything, things should be easier, as you can rattle off a practised monologue without an interviewer interrupting you to ask for clarifications.

You can probably also assume that the algorithm assessing your performance is sufficiently capable that it will be observing you at much the same level as a human interviewer. However, it is probably still worth speaking as clearly as possible with these kinds of interviews and paying extra attention to your lighting to ensure that your face is clearly visible.

No doubt the AIs scoring these interviews are improving all the time, but you still want to make their job as easy as possible. Just think about the same things as you would with a live Zoom interview, but more so.

7. How we can help

There are lots of great free resources on this site to get you started with preparation, from all our articles on case solving and consulting skills to our free case library and peer practice meeting board .

To step your preparation up a notch, though, our Case Academy course will give you everything you need to know to solve the most complex of cases - whether those are in live interviews, with chatbots, written tests or any other format.

Whatever kind of case you end up facing, nothing will bring up your skillset faster than the kind of acute, actionable feedback you can get from a mock case interview a real, MBB consultant. Whilst it's possible to get by without this kind of coaching, it does tend to be the biggest single difference maker for successful candidates.

You can find out more on our coaching page:

Explore Coaching

Of course, for those looking for a truly comprehensive programme, with a 5+ year experienced MBB consultant overseeing their entire prep personally, from networking and applications right through to your offer, we have our mentoring programmes.

You can read more here:

Comprehensive Mentoring

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How to Succeed in a Case Study Interview

How to Succeed in a Case Study Interview

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Instructor: Jena Viviano

You’ve nailed the first few rounds of interviews, and now you’ve been invited to participate in a case study interview. Curious about what this next stage of the process looks like? In this course, Jena Viviano breaks it down for you, explaining the basic components of a case study interview, how to prepare, and what to do to project confidence and engage your interviewer. Learn how case study interview questions are used and why employers find them beneficial. Discover the key elements that interviewers use to evaluate your answers. Plus, learn how to formulate key questions to dig deeper into the case, develop your own framework for every case study answer, and craft a conclusion with supporting rationale that’s concise and clear. Jena also provides tips for quelling your performance anxiety, as well as sample case study questions that give you a better understanding of what to expect.

Secrets to a successful case-study interview

January 9, 2023

Secrets to a successful case-study interview

Prepping for (and maybe fretting) the case-study interview?

While this kind of interview may appear intimidating, consider this: The interviewer really wants you to do well.

So, shake off the nerves, relax and have fun.

Tips for standing out in the case-study interview: 

  • Take your time; don't rush it.  Talk through the problem. If you can't make sense of it, take a moment and allow yourself some time to process what you've been missing. If you get stuck, get creative. Don't let yourself get bogged down; rely on your ingenuity. 
  • Ask questions.  You can always ask your interviewer to define an acronym or to repeat or confirm details. If the interviewer asks, “How do we achieve success?”, don’t be afraid to ask, “What does ‘success’ mean to you? Is it turning a profit? Raising the company’s profile?” When you work on a client project, you need to ask questions to figure out what the problems might be, and the same applies here. The interviewer is your biggest asset in the room. They have the information you need to “solve the case” successfully. Use them wisely!
  • Be flexible.  The focus of a case-study interview may vary. So, be prepared to participate in whatever discussion the interviewer has in mind. They may spend the first half of the interview asking about your previous experience, or they may dive right into the case study at the start. The bottom line: Be flexible, and be ready to discuss the work you do and how you do it.
  • Use visual aids.  Don’t be afraid to use pen and paper, sketch out your thoughts, and talk through the problem at hand if it helps you get your ideas across. What matters most is demonstrating that you can solve problems.
  • Focus on impact.  Inventory the information you have, and then dive in where you can have the most impact. Don’t forget to discuss your thought process and explain your assumptions.
  • Tell a story.  Your experience has helped you progress in your career and education; use that experience. For example, in a business case study, you could bring your experience as a traveler to a case about a hypothetical airline. Your individuality is important. Your unique insights will serve you well when you’re interviewing.
  • Pay attention to cues.  If the interviewer says something, it probably means something. Don’t dismiss seemingly extraneous details. For example, the interviewer might say, “The case is about a retailer who wants to increase the value of a company it purchased, and the owner loved the brand when growing up.” The purpose of that detail is to indicate that turning around and selling the asset is not an option for making it profitable, because the owner is attached to it.

Preparing for the job you want can take time, but it’s a worthwhile investment—especially when you receive an offer.

Your ideas, ingenuity and determination make a difference. 

Find your fit  with Accenture. 

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Anaam Zamorano

RECRUITING ASSOCIATE MANAGER, HOUSTON, TEXAS

Georgetown University.

Case Interviewing Questions

What is a case interview.

The case interview is a scenario modeled after a real business or management problem. Candidates are asked to analyze a problem and provide a solution based on the information given. The majority of cases don’t have a specific answer that you are expected to give; instead, the interviewer is looking for you to demonstrate a problem-solving process that is both analytical and creative.

Who Uses This Style of Interviewing?

Many consulting firms use the case interview as part of their interview process. The case gives candidates a sense of the type of work that consultants do and allows the employer to test the candidate’s ability to analyze, present information, and perform under pressure. However, any employer who is looking for strong problem solving and presentation skills can use case style interviewing.

Skills Evaluated During a Case Interview

  • Communication skills
  • Analytical and reasoning skills
  • Ability to organize and present information
  • Ability to perform under pressure
  • Understanding of basic business principles
  • Creativity and resourcefulness

Types of case questions:

  • Business case (most common).  A scenario to gauge the general business knowledge of candidates and how they can logically apply this knowledge. It could focus on different areas such as: profit/loss, organizational structure, and marketing. Example: “An airline finds that, while its revenues are high, the company is still operating at a loss. What is going on?”
  • Market-sizing/”Guesstimates.” Estimation questions that require the use of logical deduction and general statistical information to estimate some number or size. Example: “How many gas stations are there in the U.S.?” 
  • Brainteasers.  Puzzles or logic questions used to gauge creativity, quantitative skills, and problem-solving skills. Example: “Why are manhole covers round?” 

How to Approach a Case Interview

  • Listen to the case . Take notes and rephrase the question to make sure you’ve got all the information.
  • Clarify the problem . Ask good questions to clarify and show your understanding of the problem.
  • Analyze the problem . Pause and take time to think about how you will approach the problem. Silence is okay!
  • Structure an answer . Write out your method for solving the problem. Use examples from in and outside the classroom to show insight.
  • Share your answer . Talk through your approach using key points to guide you.
  • Summarize your findings . Provide a conclusion that restates your main points.

How to prepare for a case interview

The best preparation for a case interview is to PRACTICE. The more cases you work through, the more comfortable you will become with the process.

Use this general timeline and the resources below to structure your practice:

As early as possible :

  • Read the case resources Case in Point and the Vault Guide to the Case Interview .
  • Coordinate an informational interview with a Georgetown alum working in consulting. Use Hoya Gateway to get connected.
  • Sign up for a mock interview to practice your behavioral interview skills (these are important too!).

Two weeks before an interview

  • Review and practice cases with a friend.
  • Attend an employer case workshop.
  • Visit employer websites for each company’s tips and sample cases.

The day before the interview

  • Review our tips below.
  • Get enough sleep so that your mind will be sharp.
  • Bring paper and pens to the interview.

Case Interview Tips

  • Take notes.
  • Remember, the case is a chance to demonstrate how you think – don’t be discouraged if you don’t know the industry well. Use your analytical and communication skills to show how you would break down the problem.
  • Make sure you understand the problem you are being asked to analyze. Paraphrase back to the interviewer to make sure you heard them correctly.
  • Ask questions and listen to the answers you get (don’t be discouraged by information that the interviewer doesn’t provide, that likely means it is not important).
  • Take time to collect your thoughts (and ask for more time if you need it). Don’t be afraid of silence.
  • Lay out a road map for your interviewer (your framework will help here).
  • Think out loud to allow the interviewer to see your analytical skills.
  • Present your thinking in a clear, logical manner.
  • Summarize your recommendations and use examples from your classes, internships, or extra-curricular activities to provide insight beyond the case.
  • Read industry magazines and journals (both general and specific).
  • Familiarize yourself with some basic statistics, such as the population of the U.S.

There are several resources available both in the career center and online, which can help you prepare for case style interviews.

Case Interviewing Guides

  • Case In Point: Case Interview Preparation , 10th Edition, (Marc P. Cosentino, 2010)
  • Case Interview Secrets  (Victor Cheng, 2012)
  • Vault Career Guides  – career guides, employer profiles and rankings, and more. You must create an account with your Georgetown e-mail address to access Vault.
  • Vault Guide to the Case Interview , 9th Edition

Sample Cases & Websites

  • Management Consulting Case Interviews – hundreds of case interview questions organized by type, industry, and employer. Questions are available for free but solutions require a subscription.
  • CaseInterview.com – Sign up for free access to case interview training videos, newsletters, and strategies for success from Victor Cheng, author of Case Interview Secrets .
  • MConsulting Prep – Started by a former McKinsey consultant, this website has videos and coaching strategies for interview preparation.
  • How to Ace the Case Consulting Interview webinar , Igor Khayet (F’06)
  • Case Interview 101 – an introduction video from MConsulting Prep. 

Company Resources for Case Interview Preparation

  • Accenture’s case interview workbook (PDF)
  • Succeeding in Case Study Interviews : a blog post from an Accenture recruiter

Bain & Company

  • Interview preparation tips and interactive case studies

BCG (Boston Consulting Group)

  • Interview process and tips

Dean and Company

  • Interview preparation
  • “How to Crack a Case” presentation  (PDF)
  • Interview tips
  • Interactive cases

L.E.K. Consulting

  • Interview preparation tips with samples cases and videos

McKinsey & Company

  • Interview process, including videos, sample cases, and practice tests

Oliver Wyman

  • Interview preparation and case interviews
  • Interview preparation and process

Career in Consulting

case study job interview approach

280 Free Case Interview Examples

Do you want to get access to over 280 free case interview examples (with answers)?

If you have interviews planned at McKinsey ,  The Boston Consulting Group , or any other consulting firm, you are probably looking for case interview examples.

So, to help you prepare, I have compiled a list of 280 free case interview examples:

  • Over 30 free case interview examples (+ interview prep tips) from the websites of top consulting firms
  • More than 250 free case interview examples from top business school case books

Moreover, you’ll get  my take on which case studies you will likely have in interviews.

In short, the resources listed hereafter will be very helpful if you are starting out or have already made good progress in preparing for your case interviews.

One last word : check out this free case-cracking course to learn how to crack the most recent types of case questions consulting firms use in actual interviews.

Let’s get started!

Table of Contents

Get the latest data about salaries in consulting, mckinsey: tips and case interview examples.

McKinsey & Company’s website is definitely one of my favorites.

Because this gives so much insightful information about the role of a consultant and what the hiring process looks like.

Therefore, I highly recommend spending time on their website, even if you are not targeting McKinsey.

In the meantime, here are 8 McKinsey case interview examples

  • Electro-light
  • GlobaPharma
  • National Education
  • Talbot trucks
  • Shops corporation
  • Conservation forever

McKinsey hub

Check out the McKinsey Hub : A library of 20+ free resources that cover everything you need to secure a job offer at McKinsey.

Besides, here is another McKinsey case interview example.

This case interview question has been recently asked in a real interview:

𝘦𝘊𝘢𝘳𝘊𝘰, 𝘢 𝘑𝘢𝘱𝘢𝘯𝘦𝘴𝘦 𝘭𝘦𝘢𝘥𝘪𝘯𝘨 𝘮𝘢𝘯𝘶𝘧𝘢𝘤𝘵𝘶𝘳𝘦𝘳 𝘰𝘧 𝘦𝘭𝘦𝘤𝘵𝘳𝘪𝘤 𝘱𝘢𝘴𝘴𝘦𝘯𝘨𝘦𝘳 𝘷𝘦𝘩𝘪𝘤𝘭𝘦𝘴, 𝘩𝘢𝘴 𝘣𝘦𝘦𝘯 𝘴𝘵𝘳𝘶𝘨𝘨𝘭𝘪𝘯𝘨 𝘸𝘪𝘵𝘩 𝘢 𝘭𝘰𝘸 𝘮𝘢𝘳𝘬𝘦𝘵 𝘴𝘩𝘢𝘳𝘦 𝘪𝘯 𝘵𝘩𝘦 𝘉2𝘉 𝘴𝘦𝘨𝘮𝘦𝘯𝘵. 𝘛𝘩𝘦𝘺 𝘦𝘯𝘫𝘰𝘺 𝘴𝘵𝘳𝘰𝘯𝘨 𝘱𝘰𝘴𝘪𝘵𝘪𝘰𝘯𝘴 𝘪𝘯 𝘵𝘩𝘦 𝘉2𝘊 𝘴𝘱𝘢𝘤𝘦, 𝘣𝘰𝘵𝘩 𝘥𝘰𝘮𝘦𝘴𝘵𝘪𝘤𝘢𝘭𝘭𝘺 𝘢𝘯𝘥 𝘪𝘯 𝘵𝘩𝘦 𝘪𝘯𝘵𝘦𝘳𝘯𝘢𝘵𝘪𝘰𝘯𝘢𝘭 𝘮𝘢𝘳𝘬𝘦𝘵. 𝘏𝘰𝘸𝘦𝘷𝘦𝘳, 𝘦𝘊𝘢𝘳𝘊𝘰’𝘴 𝘴𝘢𝘭𝘦𝘴 𝘵𝘰 𝘴𝘮𝘢𝘭𝘭 𝘢𝘯𝘥 𝘮𝘦𝘥𝘪𝘶𝘮 𝘴𝘪𝘻𝘦 𝘣𝘶𝘴𝘪𝘯𝘦𝘴𝘴𝘦𝘴 𝘤𝘰𝘯𝘵𝘪𝘯𝘶𝘦 𝘴𝘵𝘢𝘺𝘪𝘯𝘨 𝘧𝘢𝘳 𝘣𝘦𝘭𝘰𝘸 𝘦𝘹𝘱𝘦𝘤𝘵𝘢𝘵𝘪𝘰𝘯𝘴. 𝘛𝘩𝘦 𝘊𝘌𝘖 𝘩𝘢𝘴 𝘪𝘯𝘷𝘪𝘵𝘦𝘥 𝘺𝘰𝘶 𝘵𝘰 𝘩𝘦𝘭𝘱 𝘵𝘩𝘦𝘮 𝘰𝘶𝘵.

How would you approach this business problem?

When ready, check this video below where I present how to approach this problem.

BCG: Tips And Case Interview Examples

The Boston Consulting Group website  states something very important: the goal of the hiring process is to get to know you better, which means, in the context of Consulting interviews, understanding how you solve problems .

Remember this: in case interviews,  to show how you think is MUCH MORE IMPORTANT than to find an answer to the case .

As a result, you will have case study questions to showcase your problem-solving skills. Likewise, fit interviews have the same purpose: to show what problems you faced and how you resolved them.

  • BCG interview prep tips
  • BCG’s interactive case tool
  • BCG case interview example: climate change challenge
  • BCG case interview example: GenCo
  • BCG case interview example: FoodCo

case study job interview approach

Check out the BCG Hub : A library of 20+ free resources that cover everything you need to secure a job offer at BCG.

Bain: Tips And Case Interview Examples

Bain & Company’s website highlights something very important: successful applicants manage to turn a case interview into a conversation between two consultants .

In other words, you don’t want to appear as a candidate but as a consultant !

To do this, you need to master the main problem-solving techniques that consulting firms want to see.

  • Bain interview prep tips here and here
  • Bain case interview examples: coffee , fashioco
  • Bain case interview sample videos: a first video , a second video

case study job interview approach

Check out the Bain Hub : A library of 20+ free resources that cover everything you need to secure a job offer at Bain & Company.

Deloitte: Tips And Case Interview Examples

As for the BCG’s section above, the Deloitte website clearly states that in case interviews , it is much more important to show how you think and interact with your interviewer than to find the right answer to the case.

  • Deloitte interview prep tips
  • Deloitte case interview examples: here (more than 15 case interview examples)
  • Deloitte case interview example: Federal Agency
  • Deloitte case interview example: Recreation Unlimited
  • Deloitte case interview example: Federal benefits Provider
  • Deloitte case interview example: Federal Civil Cargo protection Bureau

Get 4 Complete Case Interview Courses For Free

case study job interview approach

You need 4 skills to be successful in all case interviews: Case Structuring, Case Leadership, Case Analytics, and Communication. Join this free training and learn how to ace ANY case questions.

Oliver Wyman: Tips And Case Interview Examples

Like the Deloitte website, Oliver Wyman’s website points out that, above all,  you must demonstrate your ability to think in a structured, analytical, and creative way.

In other words, there are no right or wrong answers, but only showing how you solve problems matters.

  • Oliver Wyman interview prep tips
  • Oliver Wyman case interview examples: here (Aqualine) and here (Wumbleworld)

Kearney: Tips And Case Interview Examples

Now it’s time to tell you something you could have heard a hundred times.

Yet too many candidates do it.

Do NOT force your solution to adapt to a standard framework . As a result, this will only take you to a place you don’t want to go: the pool of rejected candidates .

To learn more about this, check the “What Not To Do” section on the AT Kearney website .

  • Kearney interview prep tips
  • Kearney case interview examples: here and here
  • Kearney case book: here

Strategy&: Interview Prep Tips

Strategy& doesn’t provide case study examples on its website, but it shares insights on career progression, which I recommend reading when you prepare for your fit interviews.

  • Strategy& interview prep tips

Roland Berger: Tips And Case Interview Examples

I like the examples of case studies presented on the Roland Berger website .

Because the two examples of case studies are very detailed and illustrate the kind of solutions your interviewers expect during case discussions.

  • Roland Berger interview prep tips
  • A first Roland Berger case interview example: part 1 and part 2
  • A second Roland Berger case interview example: part 1 and part 2

Alix Partners: Interview Prep Tips

Like Strategy&, Alix Partners doesn’t provide case study examples on its website.

However, they give an overview of what they are looking for: they want entrepreneurial, self-starter, and analytical candidates, which are skills that all consulting firms highly appreciate .

  • Alix Partners interview prep tips

OC&C: Interview Prep Tips

Here are two case study examples from OC&C:

  • Imported spirit
  • Leisure clubs

253 Case Studies From Business School Case Books

Most of these 253 case study examples are based on case interviews used by consulting firms in real job interviews .

As a result, you can have a good idea of the case study questions you can have when interviewing at these firms .

The Full List Of 253 Free Case Study Examples

  • Chicago business school
  • Australian Graduate School of Management
  • Columbia business school
  • Harvard business school
  • Wharton business school (2009)
  • Wharton busines school (2017)
  • Darden business school

Do you want to practice a specific type of case study? Now you can…

I have sorted this list of 253 case studies by type:  profitability, market expansion, industry analysis, pricing, investment or acquisition,  and guesstimates (also known as market sizing questions).

Full list of case study examples sorted by type

Bonus #1: Know The Types Of Cases You Are Likely To have During Your Interviews

  • Profitability cases (29% of cases from that list)
  • Investment cases (19% of cases from that list)
  • Market sizing questions (15% of cases from that list)

As a result, assuming you’ll have 6 interviews (and therefore 6 case interviews) during the recruitment process:

  • “Profitability cases are 29%”  means that chances to have 2 profitability case studies during your recruitment process are very high
  • “Investment cases are 19%”  means that chances to have 1 investment case study during your recruitment process are very high.
  • “ Guesstimates are 15%”  means that chances of having  1 market sizing question during your recruitment process are high.

Bonus #2: The 10 Cases I Recommend You Doing Now

Over 250 examples of case interviews are a great list, and you may not know where to start.

So, I’ve compiled a list of my 10 favorite case studies.

The 5 case studies I recommend doing if you are a BEGINNER

1. stern case book: drinks gone flat (starting at page 24).

This is a good introduction to a common type of case (declining sales here). I liked the solution presented for this case, particularly how it started by isolating declining sales (what range of products? Volumes or prices, or both?).

2. Stern case book: Sport bar (starting at page 46)

This is an investment case (should you invest in a new bar). Even if the solution presented in this case book is not MECE , it covers the most common quantitative questions you might have in such a case. I recommend doing this case.

3. Stern case book: MJ Wineries (starting at page 85)

This is a profitability case. I liked the solution presented in this case because it illustrates how specific good candidates should be. The case concerns wine, so a good candidate should mention the quality of lands and grapes as important factors.

4. AGSM case book: Piano tuners (starting at page 57)

This is a typical market sizing question. How to answer this type of question is a must-know before going to your interviews.

5. Darden case book: National Logistics (starting at page 49)

Again, this is a very common case (how to reduce costs). I liked the broad range of questions asked in this case, covering key skills assessed by consulting firms during case interviews: brainstorming skills (or creativity), quantitative skills, and business sense.

The 5 case studies I recommend if you are more ADVANCED in your preparation

1. stern: the pricing games (starting at page 55).

This case study asks you to help your client assess different business models. I liked this case because the range of issues to tackle is quite broad.

2. Wharton 2017: Engineer attrition at SLS Oil & Gas Services (starting at page 55)

I liked this case study because the case prompt is uncommon: your client has been facing a very high attrition rate among its population of Engineers. As a result, it’s very unlikely that your solution fits a well-known framework, and you’ll have to demonstrate your problem-solving skills by developing a specific solution.

3. Wharton 2017: Pharma Company Goes International, Outsources Benefits, Integrates New Technology (starting at page 95)

This case is about a client considering outsourcing a part of their activity. Even though I don’t know if this type of case study is very common, I had many case studies like this when I passed my interviews a few years ago. And I always found them difficult!

4. Insead: Gas retail case (starting at page 73)

The question in the problem statement is very broad, making this case difficult. So, only good candidates can have a structured case discussion here.

5. Darden: Fire Proof (starting at page 84)

This is a market entry case. Try to solve it by developing a structure as MECE as possible.

CareerInConsulting.com's Free Resources

Access my exclusive free training to help you prepare for your case interviews .

Besides, you can learn my step-by-step guide to answering market sizing questions .

You’ll get my formula to solve all market sizing questions.

Moreover, if you are a beginner, you can read my article on how to solve business cases (+ a 4-week prep plan to get case interview ready).

Also, check these 11 must-know frameworks to ace your case interviews.

Finally, you can read the articles in the blog section of my website.

That’s quite a list.

To complete this list, check this free case interview course , where you’ll find case questions recently asked in actual interviews.

Now, I’d like to hear from you.

Which key insights were new to you?

Or maybe I have missed something.

Either way, let me know by leaving a comment below.

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Home Blog Business A Guide for Case Study Interview Presentations

A Guide for Case Study Interview Presentations

You’ve been called for an interview at your dream firm and spent the entire night rote learning policies, laws, and theories to impress the panel of interviewers with your ability to retain knowledge. However, when the interview presentation begins, contrary to your expectations of being asked to recall the information you’ve memorized, you are handed a piece of paper, which entails details about a financial embezzlement scandal. You are instructed to analyze the document and provide solutions to the problems mentioned at the end of the document.

The above-mentioned hypothetical situation is an example of a case study interview, often used by professional services firms to assess and hire applicants.

case study interview cover slide for powerpoint

Table of Contents

What is a case study interview?

Why a case study interview, format of a case study interview, non-profitability cases, startup and early stage ventures, market sizing framework, profitability framework, market study framework, merger & acquisition cases framework.

  • Example Scenario 1

Example Scenario 2

A case study interview is one in which the candidate is interviewed about a scenario-based business organizational challenge that the company may have experienced. The case interview allows candidates interested in a career in consulting to exhibit their analytical, communication, and reasoning abilities. The case study interviews are constructed in such a way that they aid in identifying key issues in order to develop effective solutions. ( LSE )

To gauge a potential employee’s ability to apply theoretical knowledge to real-world situations and develop workable answers in a constrained amount of time, interviewers use the case study interview method. Big market players, like McKinsey, Deloitte, or Bain and company, use case studies in their job interviews . The interviewer may measure a candidate’s ability not just to grasp technical elements of a real-life problem, but also to come up with creative solutions, by asking case study questions.

Candidate led an interviewer led case study interview formats

Case study interviews are often carried out in one of two ways, depending on the goals and specifications of the company conducting the interview.

  • Interviewer-led interview
  • Candidate led Interview

Interviewer led

During a case study interview, the interviewer is the one who sets the tone, pace, and overall structure. It is a highly structured interview where the candidate should be prepared for a sudden change of style depending on the interviewer. The interviewer continues asking questions they’ve already prepared regardless of the candidate’s answers.

Candidate led

In contrast to an interviewer-led, a candidate-led is less regimented, and the candidate takes the wheel. They are expected to shape the Interview from start to finish. In this case, the candidate’s answers determine the line of questions. It is convenient for a firm to assess if an individual can handle situations independently by conducting a candidate-led interview.

In the final section, we’ve provided candidate- and interviewer-led interview cases in our examples.

Archetypes of Case Study Interviews

Case study interview classification infographic

Not every case study interview is centered on profit or revenue-generating scenarios. The interviewer may begin with a case of Non-Profitability. The analyzed organization might face a challenge to reach an objective. It requires a situation analysis in order to provide a diagnosis. The candidate will run the analysis, provide a diagnosis, and based on it will define a strategy to overcome the challenge and reach the objective. 

During the case interview, the focus is on strategic issues and recommendations for developing an industry’s environment while dealing with challenges. Regulations, consumer preferences, and more might all fall under this umbrella. Here, a SWOT analysis is useful in identifying the competitive landscape.

Taking into account the emerging Industrial Revolution 4.0 startup boom. The interviewer will most likely use this as an example in your case study interview. Market entry cases are comparable to startup, and early venture case studies, except the company, is smaller and employs fewer people. One must have a strong product or service in order to have a foothold in the market with significant profit margins.

The case study discussion should focus on the following three areas: the right people, the right problem, and the right solution. A minimum viable product and a well-thought-out business strategy are necessary. Startups are more likely to be agile and successful when these three characteristics are present.

In a market sizing question, commonly known as ‘guesstimate,’ the candidate is asked to estimate the size of a market randomly selected by the interviewer with little or no data available. Market size questions should be approached by segmenting data and adapting the MECE technique. In a case study interview, you may also solve market sizing problems by using the issue decision tree .

 Case study interview questions can be the following:

  • Estimate the market size of frozen foods in a suburban area of Melbourne.
  • How many individuals are currently consuming vitamin water in China?

Every firm’s ultimate goal is to earn profits; therefore, the profitability framework seeks to identify whether the candidate can correctly assess the cause of decreased profitability or ways of increasing profitability. Candidates are usually provided with names, figures, and facts to answer questions pertaining to different aspects of profitability.

A market study framework generally aids in determining an individual’s ability to assess market factors like market entry potential, revenue growth, and market share.

In order to construct a framework for a market study in a case interview, the candidate must focus on five components. The market, rivals, customers, your firm, and your product/service are all included. This market analysis methodology necessitates the candidate to ask further clarifying questions on the financial and profitability impact on the company in discussion.

The merger and acquisition cases framework is considered one of the most accurate judges of the candidate’s potential as it deals with all major components of market analysis, including but not limited to market sizing, profitability, and market study factors. These case study interview questions usually deal with whether or not two or more companies should opt for a merger/acquisition.

When addressing an M&A case, three components should be taken into account: the synergies between the two organizations, the integration of talent, technology, and so on, and regulatory approvals.

Case Study Interview Example Scenario 1

Objective: Country X is situated in Asia and has a population of 20 million. It is developing a national action plan to transform its education system. It wants to improve the quality and quantity of children’s education. The objective is to advise the client on transforming their education system.

Description: Country X is a developing nation of 20 million residents and has emerged as a free market economy after spending decades under communism. The Country aspires to have an economic action plan for transforming education. The schooling system in Country X is completely public (state managed) and has government-run schools spread throughout the Country. Children are admitted from age 5 to 18. The objective is to evaluate the current state of the education system and how it can meet the aspirations of the Government. 

This type of scenario mostly follows an interviewer-led approach. This falls under the Non-Profitability case study example. The primary purpose is to examine the issue from the top-down approach to get a higher-level view. Initially, qualitative analysis is performed.

  • The interviewer will first ask how you intend to analyze and evaluate the problem’s underlying issues.

An approach is to structure the response into three sections. A PowerPoint slide with a clear bifurcation of these three sections can be presented under a separate heading.

The initial section should emphasize some quantitative metrics of education. This encompasses observations such as how age, gender, and geography affect access to education. How many teachers are working in schools around the region? How much is spent on healthcare?

Education access infographic for case study interview

The second component is the quality of education, including the curriculum, teaching methods, etc. The second question is quantitative and requires analysis of a table containing distinct informational values relative to competitor nations.

A third element of the analysis could be to understand the effect of education in Country X’s economics objectives.

You will be provided with a table with figures for the number of pupils and teachers, health care expenditure, student-to-teacher ratio, etc. You will be expected to evaluate competitor values in comparison to Country X. Among the observations that can be made are how Country X compared to other nations regarding health care spending and the student-to-teacher ratio. The table values can be interpreted as, e.g., Country X has the highest education expenditure but has the lowest student-to-pupil ratios. All this information can be presented using SlideModel PowerPoint templates .

Comparing the observation to international standards is another way of acquiring a deeper understanding of the provided data. Because only 15 percent of Country X’s population is enrolled in school, the question is how many schools should be opened given that Country Y surpasses Country X in an international comparison. To solve such a puzzle, you will use comparable data to compute the number of schools utilizing population and school information from the provided data. This will assist you in determining a solid number to present in the Interview. The final number can be presented as a percentage or an absolute number in a much larger font on the ppt slide. SlideModel has a variety of case study templates you can choose from to showcase your result in a much more engaging manner.

These two approaches for the qualitative and quantitative aspects of the case Interview enable us to cover the fundamentals of a case study interview. 

Objective: Client Y is about to launch a new phone and desires to determine the size of the Apple product market. The objective is to determine how many iPhones Apple sells in the United States annually.

Description: Client X seeks an analysis of the current market size of the iPhone, its primary rival in the mobile phone industry. The current population of the United States is 320 million, and iPhone has a very large client base in the Country. The client requests that you calculate a number that provides a reliable estimate of the size of the iPhone market in the United States.

We will use a Three-step technique for a market size example to tackle this problem.

Step 1: Formulate the right question

To define market size, asking appropriate clarifying questions is a must. It is useful to define what the market size is and how to give a proper estimate for the market segment based on the given information.

For example:

Are we concentrating on a single iPhone model or the entire lineup?

Is it simply applicable to the United States, or do we also need to estimate worldwide iPhone sales through the US outlet?

After asking the appropriate clarifying questions, you can formulate a coherent strategy.

Step 2: Building a Framework

There are two sorts of problem-solving strategies for gauging the market questions. The top-down method and the bottom-up method.

The appropriate and easy way to solve this is to utilize top-down methodology and show it via an Issue tree. Using the MECE (Mutually conclusive and Collectively exhaustive) technique , an issue tree is a logical tree that may be depicted graphically to address difficult business challenges. It is quite common in market size questions. On the SlideModel website, you will discover a choice of templates for creating an excellent visual tool, i.e., The Issue/Logic tree.

You might convey it by beginning with the United States 320 million people.

Determine what proportion of phones are iPhones.

Identifying the frequency with which an individual purchases an iPhone each year.

And determine the number of iPhones sold based on the frequency and quantity of iPhone owners.

Step 3: Estimating and making assumptions

The estimated population of the United States is 320 million. Assuming that 75 percent of the United States population possesses a mobile phone and 30% are iPhone users because the number of smartphone users has multiplied in the digital era, we obtain: 

75 % x 320 million = 240 million Mobile Phone users.

30 % x 240 million = 72 million iPhone users.

Again, we suppose that each of these 72 million people buys an iPhone every two years. A single client will acquire one iPhone 0.5 times in a year.

Therefore, 0.5 times 72 million is 36 million iPhone sales.

To estimate the size of the iPhone market in the United States, we might assume the average iPhone price is $100.

By calculating the cost by the number of units sold a year, we get:

$100 x 36,000,000 = $3.6 billion USD.

Therefore, the annual market size for apple goods is $3.6 billion.

Calculations and estimations utilizing the said frameworks require practice and findings. SlideModel will assist you in organizing your framework and offer you visual tools to successfully convey your findings to the interviewer.

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case study job interview approach

47 case interview examples (from McKinsey, BCG, Bain, etc.)

Case interview examples - McKinsey, BCG, Bain, etc.

One of the best ways to prepare for   case interviews  at firms like McKinsey, BCG, or Bain, is by studying case interview examples. 

There are a lot of free sample cases out there, but it's really hard to know where to start. So in this article, we have listed all the best free case examples available, in one place.

The below list of resources includes interactive case interview samples provided by consulting firms, video case interview demonstrations, case books, and materials developed by the team here at IGotAnOffer. Let's continue to the list.

  • McKinsey examples
  • BCG examples
  • Bain examples
  • Deloitte examples
  • Other firms' examples
  • Case books from consulting clubs
  • Case interview preparation

Click here to practise 1-on-1 with MBB ex-interviewers

1. mckinsey case interview examples.

  • Beautify case interview (McKinsey website)
  • Diconsa case interview (McKinsey website)
  • Electro-light case interview (McKinsey website)
  • GlobaPharm case interview (McKinsey website)
  • National Education case interview (McKinsey website)
  • Talbot Trucks case interview (McKinsey website)
  • Shops Corporation case interview (McKinsey website)
  • Conservation Forever case interview (McKinsey website)
  • McKinsey case interview guide (by IGotAnOffer)
  • McKinsey live case interview extract (by IGotAnOffer) - See below

2. BCG case interview examples

  • Foods Inc and GenCo case samples  (BCG website)
  • Chateau Boomerang written case interview  (BCG website)
  • BCG case interview guide (by IGotAnOffer)
  • Written cases guide (by IGotAnOffer)
  • BCG live case interview extract (by IGotAnOffer) - See below

3. Bain case interview examples

  • CoffeeCo practice case (Bain website)
  • FashionCo practice case (Bain website)
  • Associate Consultant mock interview video (Bain website)
  • Consultant mock interview video (Bain website)
  • Written case interview tips (Bain website)
  • Bain case interview guide   (by IGotAnOffer)
  • Bain case mock interview with ex-Bain manager (below)

4. Deloitte case interview examples

  • Engagement Strategy practice case (Deloitte website)
  • Recreation Unlimited practice case (Deloitte website)
  • Strategic Vision practice case (Deloitte website)
  • Retail Strategy practice case  (Deloitte website)
  • Finance Strategy practice case  (Deloitte website)
  • Talent Management practice case (Deloitte website)
  • Enterprise Resource Management practice case (Deloitte website)
  • Footloose written case  (by Deloitte)
  • Deloitte case interview guide (by IGotAnOffer)

5. Accenture case interview examples

  • Case interview workbook (by Accenture)
  • Accenture case interview guide (by IGotAnOffer)

6. OC&C case interview examples

  • Leisure Club case example (by OC&C)
  • Imported Spirits case example (by OC&C)

7. Oliver Wyman case interview examples

  • Wumbleworld case sample (Oliver Wyman website)
  • Aqualine case sample (Oliver Wyman website)
  • Oliver Wyman case interview guide (by IGotAnOffer)

8. A.T. Kearney case interview examples

  • Promotion planning case question (A.T. Kearney website)
  • Consulting case book and examples (by A.T. Kearney)
  • AT Kearney case interview guide (by IGotAnOffer)

9. Strategy& / PWC case interview examples

  • Presentation overview with sample questions (by Strategy& / PWC)
  • Strategy& / PWC case interview guide (by IGotAnOffer)

10. L.E.K. Consulting case interview examples

  • Case interview example video walkthrough   (L.E.K. website)
  • Market sizing case example video walkthrough  (L.E.K. website)

11. Roland Berger case interview examples

  • Transit oriented development case webinar part 1  (Roland Berger website)
  • Transit oriented development case webinar part 2   (Roland Berger website)
  • 3D printed hip implants case webinar part 1   (Roland Berger website)
  • 3D printed hip implants case webinar part 2   (Roland Berger website)
  • Roland Berger case interview guide   (by IGotAnOffer)

12. Capital One case interview examples

  • Case interview example video walkthrough  (Capital One website)
  • Capital One case interview guide (by IGotAnOffer)

13. Consulting clubs case interview examples

  • Berkeley case book (2006)
  • Columbia case book (2006)
  • Darden case book (2012)
  • Darden case book (2018)
  • Duke case book (2010)
  • Duke case book (2014)
  • ESADE case book (2011)
  • Goizueta case book (2006)
  • Illinois case book (2015)
  • LBS case book (2006)
  • MIT case book (2001)
  • Notre Dame case book (2017)
  • Ross case book (2010)
  • Wharton case book (2010)

Practice with experts

Using case interview examples is a key part of your interview preparation, but it isn’t enough.

At some point you’ll want to practise with friends or family who can give some useful feedback. However, if you really want the best possible preparation for your case interview, you'll also want to work with ex-consultants who have experience running interviews at McKinsey, Bain, BCG, etc.

If you know anyone who fits that description, fantastic! But for most of us, it's tough to find the right connections to make this happen. And it might also be difficult to practice multiple hours with that person unless you know them really well.

Here's the good news. We've already made the connections for you. We’ve created a coaching service where you can do mock case interviews 1-on-1 with ex-interviewers from MBB firms . Start scheduling sessions today!

The IGotAnOffer team

Interview coach and candidate conduct a video call

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5 Ways to Prepare for Situational Interview Questions

  • Marlo Lyons

case study job interview approach

Tactical advice to help you nail common prompts.

When interviewing for a new job, anticipating and preparing answers in writing to the most common situational questions — such as how you solved a big problem, aligned stakeholders on a project, influenced someone to think a different way, worked with difficult personalities, or met a tight deadline — will ensure your answers are crisp and clear. Knowing exactly how you will approach common situational questions will help you stay calm and focused on highlighting how your unique strengths and experience make you the perfect candidate for the job. The author presents five strategies for answering situational interview questions with confidence.

Gone are the days when interviewers merely probed job candidates about their strengths and weaknesses. Today, recruiters and hiring managers are keen on assessing how candidates think and solve problems relevant to the job. To evaluate a candidate’s capabilities, “situational” or “behavioral” interview questions are commonly asked, beginning with prompts such as, “Can you tell me about a time when…” or “What would you do if…?”

  • Marlo Lyons is a career, executive, and team coach, as well as the award-winning author of Wanted – A New Career: The Definitive Playbook for Transitioning to a New Career or Finding Your Dream Job . You can reach her at marlolyonscoaching.com .

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  • Volume 33, Issue 3
  • What can Safety Cases offer for patient safety? A multisite case study
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  • http://orcid.org/0000-0003-4981-1210 Elisa Giulia Liberati 1 ,
  • http://orcid.org/0000-0003-1979-7577 Graham P Martin 1 ,
  • http://orcid.org/0000-0001-9514-1890 Guillaume Lamé 1 , 2 ,
  • Justin Waring 3 ,
  • http://orcid.org/0000-0001-7356-5342 Carolyn Tarrant 4 ,
  • http://orcid.org/0000-0002-7886-3223 Janet Willars 4 ,
  • Mary Dixon-Woods 1
  • 1 THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care , University of Cambridge , Cambridge , UK
  • 2 Laboratoire Genie Industriel , CentraleSupélec, Paris Saclay University , Gif-sur-Yvette , France
  • 3 Health Services Management Centre , University of Birmingham , Birmingham , UK
  • 4 Department of Population Health Sciences , University of Leicester , Leicester , UK
  • Correspondence to Dr Elisa Giulia Liberati, THIS Institute (Public Health and Primary Care), University of Cambridge, Cambridge, UK; elisa.liberati{at}thisinstitute.cam.ac.uk

Background The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. We examined the first documented attempt to apply the Safety Case methodology to clinical pathways.

Methods Data are drawn from a mixed-methods evaluation of the Safer Clinical Systems programme. The development of a Safety Case for a defined clinical pathway was a centrepiece of the programme. We base our analysis on 143 interviews covering all aspects of the programme and on analysis of 13 Safety Cases produced by clinical teams.

Results The principles behind a proactive, systematic approach to identifying and controlling risk that could be curated in a single document were broadly welcomed by participants, but was not straightforward to deliver. Compiling Safety Cases helped teams to identify safety hazards in clinical pathways, some of which had been previously occluded. However, the work of compiling Safety Cases was demanding of scarce skill and resource. Not all problems identified through proactive methods were tractable to the efforts of front-line staff. Some persistent hazards, originating from institutional and organisational vulnerabilities, appeared also to be out of the scope of control of even the board level of organisations. A particular dilemma for organisational senior leadership was whether to prioritise fixing the risks proactively identified in Safety Cases over other pressing issues, including those that had already resulted in harm.

Conclusions The Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.

  • Patient safety
  • Qualitative research
  • Risk management

Data availability statement

No data are available.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016042

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Safety Cases are a well-established regulatory technique in some areas, requiring organisations to make the case to the relevant regulator that they have put in place adequate measures to reduce risks in their systems to a level ‘as low as reasonably practicable’ (ALARP).

Importing of safety practices from other sectors has a long track record in healthcare, but little is known about the potential of the Safety Case approach when applied to clinical pathways.

WHAT THIS STUDY ADDS

It was difficult for clinical teams to use the Safety Case as intended (to show that risks had been reduced to ALARP), not least because they often identified issues that front-line staff could not address.

Safety Cases were sometimes used instead to attract senior leaders’ attention and to make the case for better support and resourcing, but some issues were beyond the control even of organisational leadership.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Safety Cases may have some potential in healthcare, but their optimal use in this sector may require modifications, particularly if they are considered for regulatory purposes.

Introduction

Patient safety remains a major challenge for healthcare, despite more than two decades of sustained policy, practice and research attention. 1 2 The initial enthusiasm for borrowing practices and methods from other safety-critical industries (such as aviation) at the outset of the patient safety movement 3–5 has been tempered by experience. 6–12 It is now widely recognised that attempts to transfer approaches between contexts require care and caution, and should be supported by theory and empirical evaluation. 13–15 This paper seeks to contribute to addressing this need through examination of an attempt to introduce into healthcare a specific safety approach—the Safety Case—that is already used in other industries (including oil, transport and mining) both as a regulatory technique, 16 and, more rarely, as a quality management approach without regulatory mandate (eg, in the automotive industry). 17 18

The specifics of the Safety Case approach vary between sectors and regulators, 19 but the general principles are listed in box 1 . In brief, a claim to operational safety is justified through a series of linked arguments that explain how safety has been secured, with supporting evidence , including the processes in place to control risk. Where used as a regulatory technique, Safety Cases are produced by organisations to ‘make the case’ to the relevant regulator that they have put in place adequate measures to reduce risks in a product or system to a level ‘as low as reasonably practicable’ (often abbreviated as ALARP). The regulator then reviews the Safety Case and either grants the organisation licence to operate, or may require further risk assessments, justification of the measures proposed or additional risk mitigations. 20

Typical features of safety cases

Safety Cases are developed to ‘make the case’ that risk has been reduced to a level ‘as low as reasonably practicable’ (ALARP). To do so, Safety Cases integrate various forms of prospective risk management analysis, based on the idea that operators are better placed than external regulators to assess risks in their own systems. The core of the Safety Case is typically a risk-based argument and corresponding evidence to demonstrate that all risks associated with a particular system have been identified, that appropriate risk controls have been put in place, and that there are appropriate processes in place to monitor the effectiveness of the risk controls and the safety performance of the system on an ongoing basis. 23

Safety cases typically contain:

A description of the system and its operational context;

How safe the system is claimed to be and the criteria by which safety is assessed;

How hazards have been identified and how the risks they pose have been assessed;

What kind of risk control measures have been put into place and why they are effective; and

Why the residual level of risk is acceptable. 23

Safety Cases are typically reviewed and assessed by an external regulator, for example, in the nuclear or petrochemical industries in the UK. However, some industrial sectors have also deployed the approach outside of a regulatory requirement. For example, the automotive industry uses Safety Cases that are part of the ISO26262 standard, but this is not mandated by regulators. 17 18

As an approach requiring organisations to proactively describe what procedures and actions they are putting in place to control risk, Safety Cases can be contrasted with prescriptive, compliance-oriented approaches, where organisations are required to show that they have met externally imposed safety standards. 21 Because they are written for a specific system and its context of use, they are intended to be more adaptable to specific situations than generic safety standards, and also more responsive to rapid change in technologies or practices. 22

On the face of it, the Safety Case would appear to have value as an approach to safety management in healthcare, particularly in its potential for prospective identification and control of risk. However, the Safety Case approach has only rarely been used in healthcare, and only in a very limited number of applications (eg, development of information systems and medical devices). 23 24 In this article, we develop an analysis of the application the Safety Case approach within the UK National Health Service (NHS) using a case study of the first documented attempt to apply the principles of the methodology to clinical pathways. As the approach was deployed outside a regulatory context, our analysis focuses on the transferability of an approach to risk management that is proactive, structured, and tailored in nature and that presents evidence about the safety of specific clinical systems and existing mitigations in a single ‘case’ document.

Case study: the Safer Clinical Systems programme

Our analysis draws on an evaluation we conducted of a programme known as Safer Clinical Systems, which is designed to improve the safety and reliability of clinical pathways based on learning adapted from a range of hazardous industries. It seeks to enable organisations to make improvements to local clinical systems and pathways through a structured methodology for identifying risks and re-engineering systems to control risk and enhance resilience. 25 26 Use of the principles of the Safety Case approach is a centrepiece of the Safer Clinical Systems programme, although outside a regulatory context.

Funded by the Health Foundation, the Safer Clinical Systems programme was developed by a team at Warwick University and tested over a number of phases. Following initial development, a ‘testing phase’ involving eight NHS hospital sites (seven in England, one in Scotland) ran from 2011 to 2014. An ‘extension phase’ (2014 to 2016) involved further work by five of these sites and one new site.

Each participating hospital site ( table 1 ) was required to establish a multidisciplinary clinical team. Sites in the testing phase were advised by a support team of clinicians and experts, received inperson training, had access to other resources (such as a reference manual and telephone support) and were required to report their progress regularly. Sites in the extension phase had less bespoke support and were expected instead to build on their previous learning.

  • View inline

Sites involved in the programme

A requirement of participating teams was that they use the Safer Clinical Systems approach to proactively assess risks and hazards in their clinical pathways and that they produce Safety Cases at the end of their projects describing the risks and how they were being mitigated. The Safety Cases were expected to be similar in format to those used in other sectors, 27 comprising a description of the clinical pathway covered, the key hazards identified through structured analysis using prescribed tools, the risk controls implemented, and, critically, a ‘safety claim’ and associated ‘confidence argument’—a pronouncement on the current safety of the system concerned, and a statement explaining how risks had been made ALARP. Rather than being presented to an external regulator, as would be the case if the Safety Case were being used as a regulatory technique, the principal intended audience in this programme was the senior leadership (executive and board level) within organisations.

Evaluation methods

To study the testing and extension phases of the Safer Clinical Systems programme, we used a mixed-methods, longitudinal design, involving interviews, ethnographic observations, and documentary analysis across the nine participating sites. The analysis we report here is based primarily on interviews and documentary analysis. Ethnographic observations (over 850 hours) provided valuable data on how clinical teams carried out their Safer Clinical Systems projects in practice in the context of existing and competing demands, but are not reported in detail here.

Across the nine sites, we conducted 89 semistructured interviews in the testing phase and 39 in the extension phase with participating clinical team members and programme leaders. Sampling at the sites sought to purposefully include a range of different roles in the programme, including the clinical leaders of each project and others. We also conducted 5 semistructured interviews in the testing phase, followed by 10 in the extension phase, with organisational senior leadership, comprising executive team/board members. Interviews explored general experiences of the programme as well as specific exploration of using the Safety Case approach. Participants were informed of the aims and commissioners of the evaluation. All interviews were conducted by experienced social scientists using topic guides ( online supplemental material 1 ). Interviews were conducted either in person or by telephone, between November 2012 and June 2016, and were digitally audio recorded and then transcribed for analysis.

Supplemental material

Analysis, conducted by EL and guided by the wider team, was based on the constant comparative method 28 combining inductive and deductive approaches. We coded interviews and observations using an inductive approach, deriving codes directly from each interview and then progressively clustering codes in higher order categories and themes. To strengthen explanatory power, this inductive strategy was complemented by theoretical concepts drawn from the wider literature.

GL and EL conducted a documentary analysis of the Safety Cases prepared by the clinical teams ( table 2 ). We used recommendations and guidelines for writing and maintaining safety cases in other sectors, 29–31 to organise the Safety Cases’ content thematically, and identified their main strengths and weaknesses in terms of completeness, presence of appropriate evidence and analyses to support the claims, consistency with the site’s safety improvement objectives, readability, and presence of a safety claim and confidence argument.

Format and content of 13 Safety Cases reviewed

Finally, we organised our higher order themes and overall reflections using concepts and themes proposed by recent works on the topic. 19 32 Regular team meetings and correspondence provided oversight of the analytical approach, consistency and adequacy of codes, and reporting. Given the nature of the programme, we did not undertake a formal test for theoretical saturation for the interviews or the Safety Cases.

Across the testing and extension phases of Safer Clinical Systems, we undertook 143 interviews with participants across programme leadership, clinical teams and organisational leadership. We analysed 13 submitted Safety Cases; although 14 should have been developed, one site from the extension phase struggled to implement the programme in full and did not produce a Safety Case.

In presenting our analysis below, we consider, first, participants’ views on the Safety Case as a novel approach to understanding and managing safety risk in healthcare, and second, the work that went into developing Safety Cases. We then turn to the analysis of Safety Cases themselves.

Views on the value of safety cases

By the end of the programme, members of the project teams and senior leadership in the participating organisations had largely come to see the Safety Case as a valuable approach, with the potential to make hazards visible in an accountable, systematic and scientific way. The analytical steps required to compile a Safety Case, such as process mapping the patient pathway, were seen to be particularly useful in proactively identifying threats to safety, rather than reactively managing incidents once they had happened. The role of Safety Cases in enabling an overarching, system-wide view of the hazards, rather than focusing on what happens in particular segments of the pathway, was also welcomed. Broadly, teams valued the possibilities of new ways of thinking about risk.

I like the idea that you just have one document that you can hand to somebody and say how safe is your system. I like the concept that you can say ‘Well this is what our system is like just now’. (Project participant)

Some organisational senior leaders agreed, at least in principle, that Safety Cases could offer value, and recognised the importance of a prospective approach to safety.

We have immensely complex systems which could be simplified and therefore made a bit more reliable. […] So something which looks at that could certainly be a useful thing, because it’s saying ‘Well actually here is a little nest of complexity which you can reduce, but it’s also a significant risk to the patient, because you’re missing information or you’re hurrying things through.’ […] (Senior leader)

Other senior leaders, however, were not always clear on the practicalities of the approach, and some found it difficult to identify the added value of Safety Cases. They suggested, for example, that existing risk management tools performed very similar functions.

If you look at our risk register, mitigation is the last box, we spend a good amount of time on the other things, but if we were to spend any time on a particular risk it would be on mitigation […]. And so that sounds like a very similar process, and so I’m back to what the delineation is between Safety Case and risk register. (Senior leader)

Some project teams saw the Safety Case as useful for a secondary reason: that of securing the attention and interest of senior leaders in their organisations. Their hope was that, by providing new evidence and analysis of the riskiness of clinical systems, senior management attention, support, and resources might be solicited.

So they’ve [senior management] actually kind of bought into it, so I think they will feel pressure to deliver. (Project participant)

However, as we explain below, the exact fit of Safety Cases into the existing ecology of tools and documents in healthcare was not clear to all participants.

Preparing safety cases

Project teams were required to learn new techniques to prepare the Safety Cases, including use of systematic methods to identify and assess risks in their clinical pathways, to propose risk controls and to identify metrics that could be used to monitor systems. Production and communication of Safety Cases also required skills in making persuasive claims, structuring arguments and presenting evidence compellingly. The participating teams were, understandably, unfamiliar with many of these skills, and expressed uncertainties about the expected structure, content and style of the Safety Case itself, especially in terms of what issues to emphasise and how to evidence them. Participants described compiling and drafting the Safety Case as labour-intensive and difficult.

I think the other bit that we have been challenged by is the actual writing of the Safety Case and again it is because it is fairly new to healthcare in general. I think we are going to go through a few reiterations before we fully understand what it is and how to use it. (Project participant)

Notwithstanding the training and support received in the ‘testing’ phase, teams continued to report difficulties with preparing and drafting Safety Cases well into the extension phase. A recurrent source of ambiguity related to the size and scope of the clinical system that the Safety Cases should target. The first, diagnostic, step in the Safer Clinical Systems process involved defining the clinical pathway of focus. However, determining the boundaries of the pathway was far from straightforward. Furthermore, clinical pathways typically involved dozens of technological systems (eg, infusion pumps, IT systems) and sociotechnical processes (eg, guidelines, multidisciplinary meetings). Each might be amenable to risk assessment and management individually, but making sense of their connections, aggregate risks and potential interactions was a much more complex task.

It’s not a linear process and you do go back trying to understand another bit of the process that you thought you understood, but actually didn't as (…) you had hoped. (Project participant)

Once the pathways and their components had been determined (or at least approximated), project teams used a range of methods recommended by the Safer Clinical Systems programme, mostly derived from similar activities in other industries, to assess hazards and risks. The teams found the processes often challenging and time-consuming, with much discussion about the relative merits of different sources of data and evidence. Despite the challenges, teams generally concluded that conducting a systematic risk assessment using structured tools offered important new insights about clinical pathways.

What I’ve loved doing is, is talking to the staff and actually understanding what goes on, because it’s only when you understand what goes on that you can put it right… You’ve worked in the hospital for years and there’s still things you didn’t realise actually went on and things that people did that you didn't realise that they actually did. That was quite an eye-opener. (Project participant)

This new understanding through structured risk assessment enabled teams to identify multiple shortcomings that had potential to harm patients. The hazards they unearthed varied greatly in scale, level of risk posed and tractability to intervention. Some problems identified were amenable to resolution by the project teams, typically those with their roots in suboptimal service planning and pathway design, failures in communication among staff, or unclear distribution of responsibility or ownership of key processes. In response to these, most, but not all, sites designed or implemented some risk controls and documented them in their Safety Cases.

[Staff are] given the freedom and the autonomy to go ahead and do whatever things they think might be necessary to make things better. And that’s what people do, there is very much a culture of promoting change there, so they talked about small cycles of change, doing PDSA [Plan Dp Study Act] cycles, and there’s a number of different projects that are running (Observation notes)

The extent to which these risk control interventions were consistent with the principles of the Safer Clinical Systems programme varied by site. Some project teams were able to draw on extensive experience, while others foundered at this stage. Common to all sites, however, was the identification of issues that were well beyond the scope of control of the front-line teams themselves. These vulnerabilities tended to originate from deep-rooted institutional and organisational pathologies or constraints. The importance of these problems, including, for example, staffing levels, was beyond doubt. Exactly what to do about them was less clear. Some project teams made valiant attempts to at least mitigate the risks through local work, but others appeared to accept that standard quality improvement efforts would not solve the issues. Some teams described the ongoing failure to mitigate the risks in their Safety Cases, in part, as noted above, in the hope that action from senior level might be provoked.

There were other things that were discussed at the [meeting] that they thought would be good as a team to change… but with some of them, they just knew it would be impossible to do so, so actually they didn't even bother to write them down. (Observation notes) And the team very bravely went to the board and said, you know, our Safety Case is showing and we're telling you that our processes are unsafe, so it alerted people to the issues. […] So that was the strength of it. (Project participant)

However, as we now describe, for senior organisational leaders, both the imperative offered by the Safety Case and their own ability to act were less clear.

Content of, and responses to, safety cases

Our documentary review showed that submitted Safety Cases were highly variable in format and length ( table 2 ). Some were highly structured, clearly written and precise in the use of evidence; others were harder to follow, lacking in clarity and less well organised. Our review also found that the descriptive elements (analysis of risk and hazards) were much better achieved than the assurance components (the safety claim and the confidence argument). Indicative, perhaps, of the intractability to local-level intervention of some of the hazards uncovered, or the lack of expert safety science input in the project teams, most Safety Cases focused more on what had been done to determine the risk than on the level of safety that had been achieved in mitigating it. The documents also varied in the extent to which they reported the residual risks—those that remained despite the implementation of risk controls—in a clear and transparent way. For instance, one Safety Case noted that the diagnostic process had found 99 ways in which the pathway could fail, that the level of reliability in the microsystem remained lower than acceptable, and that radical re-design was needed. Others were more circumspect. Accordingly, while they documented sometimes-extensive mitigations, none of the Safety Cases could make an unambiguous safety claim supported by a powerful confidence argument. Some teams were not clear about how the evidence gathered and analyses conducted would contribute to the safety claim. Some sites listed project activities in lieu of offering an actual safety claim, reporting what they had done rather than the level of safety they had reached.

It was a useful, […] a really good repository for all the stuff we've done in the project, which I find really good. And has been good when people ask ‘What did you do?’ then you can say that this is what we did, so that’s useful. I'm not sure about whether people use it for what it is meant to be, which is to prove the pathway is now safe, I’m not sure whether it is used for that really. (Project participant)

Sometimes, safety claims were reported for each identified hazard (comparing levels of risk before and after the interventions they had implemented) rather than at the level of the clinical system. No site explicitly discussed whether risks had been reduced ‘as low as reasonably practical’. Some sites claimed improvements as a result of the interventions they had implemented, but these did not always stand up to statistical scrutiny. 33

The response of senior leadership to the Safety Cases submitted by teams varied. Some focused on the potential of the Safety Case for supporting organisational-level decision making in relation to risk reduction, resource allocation and strategic prioritisation.

I think it would be easier to respond to a Safety Case rather than more so the [other quality and safety] data I get. Because it’s back to first principles, what are we actually here to do… Then if we have an unsafe system everything else needs to fall in behind that, no matter cost pressures, no matter personal opinion, no matter all the other complexities in a big system. If an element is at risk, then that will always be made a priority. (Senior leader)

Not all senior leaders, however, were so confident that the insight offered by Safety Cases would or should inevitably lead to action. Some of the issues identified in the Safety Cases were beyond the ability not only of front-line teams to solve, but also of organisational leaders. Issues such as staffing levels, IT interoperability, and securing timely discharge required at least interorganisational coordination, resourcing, coordination, and support across the whole healthcare system. Additionally, the prevailing approach to risk management, and the perceived unavoidability of risks in the complex systems of healthcare, meant that the insights offered by a Safety Case might be unwelcome or not necessarily candidates for priority attention. In a system that relied primarily on retrospective risk management approaches, such as incident reporting and investigations, the need to tackle risks of recurrence (where problems had already manifested as serious incidents or ‘near misses’, and might do again) could easily take precedence over addressing seemingly ‘theoretical’ risks (problems identified through a detailed prospective analysis but yet to occur).

Because you’re saying actually ‘That was a potential harm on our risk management system, and we knew about it, and we were accepting that we don’t have enough money to address all of these issues at one time’. So there is, if you like, a prioritisation and rationing of where we put money according to the level of risk. […] It’s a bit like county councils putting crossings on roads, or a zebra crossing. You’re waiting for the fatality to occur before actually that will get the funding. (Senior leader)

Some feared that, given the legal obligation of boards to take action in response to safety risks that were revealed to them, an unintended consequence of the Safety Case approach might be to distract organisational focus from areas that were at least as worthy of attention but lacked the spotlight offered by the Safety Case. There was a perception that to have a Safety Case for every pathway or area of practice would likely be impossible, and that too many Safety Cases would be overwhelming.

The complexity of health care is such that there are hundreds of complex connected pathways that patients are on and so… You in theory could write hundreds [of Safety Cases] and that would then become meaningless because if you write hundreds no one would ever read them. So, I think it might be helpful in some specific examples… Rather than being something that could cover everything that we do to patients. (Senior leader)

Consequently, Safety Cases might serve not to assure about control of risks, but to unnerve—and unnerve leaders who were not always well placed to act, given the scope of their control and the other priorities they faced. In a system where Safety Cases were new, without an established function in safety management, and covering only a small proportion of safety-critical activity, the information they provided was not always readily actionable from a managerial perspective and, moreover, had potential to create uncontrolled reputational risk.

The danger is that what you have is a legal requirement to spend money on a Safety Case that actually is of low, relative risk to harms that are occurring in the absence of Safety Cases. So what you get is a spurious diversion of money to a wheel that has been made very squeaky, but actually isn’t causing harm… There’s the risk of diversion to get a perfect patch in one part of the system while everything else is actually terrible. (Senior leader) (A danger) is, you know, if it does get into the wrong hands, particularly with the media, because there’s not the openness and the ability to manage some of this data, which needs explanation. But we do pride ourselves on being a very open and transparent board. (Senior leader)

Our examination of an attempt to introduce the principles and methodologies of the Safety Case approach into healthcare suggests that the approach was broadly welcomed by participants in our study, but was fraught with challenge. In other sectors, the Safety Case rests on the ALARP principle. While the Safety Cases produced by participating teams in the Safer Clinical Systems programme did present proactive analyses of risks, they did not show that the risks in clinical pathways on which they focused had been reduced as far as reasonably possible. Instead, teams identified multiple residual risks that had resisted efforts at control and mitigation by the teams themselves. These findings emphasise the importance of careful consideration of context and implementation when transferring safety management approaches from one setting to another. 12 34–36 The evidence underlying other industrial risk management techniques (eg, Failure Modes and Effects Analysis, 37 ‘5 Whys’ 10 or Root Case Analysis 11 ) is also weak, but the regulatory function of Safety Cases warrants specific caution. Sujan et al ’s review of various sectors nonetheless concluded that even with the differences in regulatory context, healthcare organisations could benefit from using the Safety Case approach to develop understanding and exposition of their current levels of risk. 19 Our study does suggest that Safety Cases show some promise as a way of structuring more responsive, adaptable and specific proactive safety management practices in healthcare settings, but further careful development and evaluation are needed, particularly if consideration is given to using them for regulatory purposes. 19

An important feature of the programme we examined—essentially a feasibility study—was that the Safety Case approach was being used outside the regulatory frameworks and infrastructures characteristic of use of the technique in most other sectors. Without an external regulatory requirement to satisfy, participating organisations in the Safer Clinical Systems programme may not have felt a strong imperative to make the responses that might otherwise be expected; absent the spectre of regulatory action, senior leadership may not have felt compelled to reduce the risks ALARP. However, even when Safety Cases are part of a regulatory framework, they are not always rigorous or successful in controlling risk 38 or showing they have been reduced ALARP. 39 While our study does not allow conclusions to be drawn about what might happen if Safety Cases were included in a regulatory regime in healthcare, it does allow insights into the nature of the challenges that might be anticipated should regulators consider introducing the approach in healthcare settings.

Some of the challenges we identified arose from the mismatch between the complexity and interdependencies of clinical pathways, with their often unbounded character, and the more tightly defined (and often more mechanical or technical) applications of the approach in other industries. 22 40 Future research might usefully clarify whether and how the scope of a Safety Case could best be defined for healthcare settings, noting that the highly dynamic and interdependent nature of multiple subsystems of care may defy attempts to impose clear boundaries. These kinds of questions are becoming increasingly prominent in safety science as recognition grows that the development of networked complex systems (eg, unmanned aircraft systems) requires a shift from relatively static prelaunch assessment to a dynamic approach that can accommodate changes in the system’s properties and behaviour during its life-cycle. 41 42

Other challenges arose in the demanding nature of the expertise, skill and time commitment required to engage in the tasks of conducting safety analyses, identifying and testing risk controls, and compiling a Safety Case. The variable quality of the Safety Cases submitted by clinical teams in this programme is likely to be linked to variable competencies and available capacity. In contrast, in safety-critical industries where these risk assessment techniques originated, the design of effective risk controls is the responsibility of safety/reliability engineers with extensive training and expertise. For healthcare, use of the Safety Case approach will require additional resource and new dedicated roles with specific expertise, rather than relying on making further demands of existing clinical teams. 40 43 The resourcing implications of a wholesale effort to shift the regulatory system and culture of an entire sector could, however, be enormous, especially given the volume and complexity of activity in healthcare and the number of diverse clinical pathways.

An additional set of challenges was more cultural in character, and related to the revelatory potential of the Safety Case. On one hand, participants—especially clinical teams—appreciated the value of the Safety Case in offering a proactive, prospective and rigorous approach to identifying safety risks. Some also saw it as a means of attracting managerial attention and obtaining resources. 44 But leaders in organisations were not always convinced that the approach offered much that was new, suggesting that more evidence would be needed to demonstrate the added value of Safety Cases—especially in moving beyond description to solution, 45 and adding value over current approaches such as risk registers. A further concern at the leadership level was that it was unclear whether areas that did have a Safety Case should be considered to have a stronger warrant for action than those that did not. A framework for supporting prioritisation of risks is likely to be helpful in any future use of Safety Cases. However, current tools, such as risk matrices, may be flawed, 46 47 so better tools should be investigated.

Even less tractable was what to do about some of the problems reported in the Safety Cases. Clinical teams had done their best to implement risk controls where they could, but they did not have sufficient power and access to resources to address those that were institutional or structural in character. They therefore often fell back on weaker administrative measures, like training or procedures. 8 Yet organisational leaders were often similarly challenged, given their limited capacity and resources for radical systems re-design, improved staffing, IT infrastructure, or other major re-engineering or influencing of activities outside the organisation itself. These findings are indicative of broader problems with the selection of risk controls in health services 44 48 that may need to be addressed before Safety Cases could achieve their potential.

Our study has a number of strengths, including its in-depth, mixed-methods, longitudinal design with engagement both with the project teams and senior leaders in organisations. It was limited in its ability to assess the impact of the Safety Case approach in improving safety, not least because of issues with data on processes and outcomes. 33

Conclusions

The Safety Case approach offers promise in principle as a safety management approach in healthcare, but substantial challenges need to be addressed before further deployment, particularly in regulation. Further experimentation with the use of Safety Cases in healthcare might therefore more profitably focus on how to make the most of their assets—including the new insights offered by prospective, system-wide risk analysis—while managing their potential unintended consequences.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by the East Midlands – Leicester Research Ethics Committee (12/EM/0228). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We thank the people from the nine sites who participated in the Safer Clinical Systems programme and the support team. We also thank colleagues on the evaluation team, including Sarah Chew, Liz Shaw, Liz Sutton, and Lisa Hallam.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

  • Data supplement 1

Twitter @graham_p_martin, @carolynctarrant

Contributors EL and GL produced the first draft of the article, subsequently revised by GM, JWa, and MD-W. EL and JWi collected the data, analysed by EL and GL. All authors contributed to data interpretation, manuscript writing and reviewing, and approved the final version. MD-W was the study Chief Investigator and study guarantor.

Funding This study was funded by the Health Foundation, charity number 286967. The Healthcare Improvement Studies (THIS) Institute is supported by the Health Foundation – an independent charity committed to bringing about better health and health care for people in the UK. The views expressed in this publication are those of the authors and not necessarily those of the Health Foundation.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Linked Articles

  • Editorial Changing the patient safety mindset: can safety cases help? Mark Sujan Ibrahim Habli BMJ Quality & Safety 2023; 33 145-148 Published Online First: 24 Nov 2023. doi: 10.1136/bmjqs-2023-016652

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  • Open access
  • Published: 23 February 2024

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study

  • Gwendolyn Mayer 1 ,
  • Diana Lemmer 2 ,
  • Ina Michelsen 1 ,
  • Pauline Schrader 2 ,
  • Hans-Christoph Friederich 1 , 3 &
  • Stephanie Bauer 2 , 3  

Journal of Eating Disorders volume  12 , Article number:  32 ( 2024 ) Cite this article

Metrics details

Introduction

Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.

To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.

Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.

Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists’ point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.

Conclusions

Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

Plain English Summary

Digital mental health interventions are therapeutic services for people with a mental disorder that can be delivered on electronic devices. They are getting increasingly important, as many patients have to wait long for a therapy. In eating disorders these interventions are still in early stages. Twenty-four telephone interviews were held with German professionals treating adolescent and adult patients with eating disorders. The aim was to understand their experiences, perspectives, and expectations regarding digital mental health interventions and to find out what is needed to integrate them into care in the future. In general, the interview partners showed positive attitudes towards these interventions. However, only few reported experiences and many obstacles were observed. The highest potential was seen for the use in addition to care outside the hospital setting and after treatment has ended. However, in case of a severe eating disorder, such as anorexia, or self-harm and suicidality, they were against the use of digital interventions. A stable personal relationship to their patients was seen as particularly important before recommending a digital intervention. Finally, the interview partners felt not informed in a sufficient way on the scientific basis and regulations regarding digital mental health interventions.

Eating disorders (EDs) cover a number of serious mental disorders in their three main forms: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Their lifetime prevalence in Western countries is estimated to be 1.9% for any ED in both sexes and up to 2.6% for women [ 1 ]. Patients suffering from an ED have a substantially reduced quality of life due to a high disease burden, a chronic disease progression, mental and physical comorbidities, and an increased mortality rate [ 2 ]. Typically, EDs show an age of onset in early adolescence with a peak incidence period of 13–18 years [ 3 ]. However, an increasing number of children are also affected and often remain untreated [ 4 ]. There is still a huge gap between treatment needs and the timely provision of support due to a lack of therapists on the one hand and patient-related factors on the other. Many patients still face stigma and shame, or fail to see the severity of their illness [ 5 ]. A recent analysis of secondary data from Germany has shown that only a quarter of those affected by an ED receive outpatient psychotherapy [ 6 ].

Electronic devices get increasingly important for the delivery of support. Especially during the pandemic, a substantial share of patients with an ED received psychotherapy with the help of a video-based software [ 7 ]. But even apart from contact restrictions during the pandemic, so-called digital mental-health interventions (DMHIs), also known as e-health, internet-based, web-based, or online interventions, got more and more present as an emerging field of innovative delivery of mental healthcare. They can include many components, such as mood tracking or cognitive tasks and may be delivered on different devices, such as mobile phones, tablets, or computers. An increasing offer of DMHIs for the most common disorders, such as depression and anxiety, is available in app stores with lacking scientific evidence [ 8 , 9 ]. However, growing evidence has been shown in randomized controlled designs of DMHIs that follow a guided cognitive behavioral therapy format, i.e. offer therapeutic support [ 10 , 11 ].

Still, the evidence regarding DMHIs for EDs remains limited. A review of Ahmadiankalati et al. [ 12 ] identified 12 RCTs with a variety of interventions with and without therapist support. Linardon et al. [ 13 ] reviewed 36 RCTs on DMHIs for EDs, but only 8 of them targeted treatment. Both reviews concluded that the studies suffer from low quality so far, high drop-out rates, and inconsistent intervention acceptability. Yet, there is a growing number of smartphone apps in app stores related to EDs. Two recent reviews investigated the types and therapeutic components of apps available in the marketplace. First, Wasil et al. selected 28 apps and found some elements of empirically supported treatments such as self-assessments, cognitive restructuring, and activity scheduling. However, only four apps were used frequently, and the authors recommend clinicians to get familiar with these interventions as patients might have had experiences with them [ 14 ]. Additionally, another study team found 65 apps in 2021, and only seven percent of them had been scientifically evaluated. Again, most of the literature focused on a small number of apps [ 15 ].

Specifically, adolescents show a high vulnerability for EDs, which has even increased during the pandemic [ 16 ]. There is only a limited number of studies investigating the effectiveness of DMHIs for the age group until 18, a review on 4 studies showed a decrease in ED symptomatology [ 17 ]. A more recent scoping review with a broader age group as target participants (10–25) assessed 49 studies that showed moderate to large effects in symptom reduction for video-based psychotherapy, but inconsistent results for internet self-help programs and no effects for mobile applications [ 18 ]. Only few studies investigated the use of mobile applications, that were perceived as acceptable but lacking privacy and features of personalization. Small to moderate effects were observed for mobile apps, if they were used within a hybrid format adjunctive to an ongoing face-to-face therapy [ 18 ].

An important prerequisite for the effective use of DMHIs is their acceptance. Individuals in Australia, the U.S. and the United Kingdom with self-reported symptoms but no diagnosis have been found to be more positive about internet-delivered or mobile interventions than individuals who have been diagnosed with an eating disorder [ 19 ]. To improve patients’ access to DMHIs, clinicians have been identified as potential gatekeepers. This shows the importance of understanding concerns that they may raise and obstacles that they may see. Main issues identified in the past related to financial and regulatory questions, such as reimbursement, credentialing and liability [ 20 ]. In Germany, the recently launched digital healthcare act provided legal regulations for the clinical use of certified digital interventions [ 21 ]. A previous study of the first author few months before the launch of this act has shown that medical experts in Germany had only little knowledge of DMHIs [ 22 ]. Another German study team found that even two years after the new legislation, the uptake and usage of these interventions are still slow and healthcare providers are reluctant to prescribe DMHIs [ 23 ].

To date, little is known about the views of clinical experts for EDs on the application of DMHIs. Only one study so far has put a focus on the perspectives of German stakeholders regarding online interventions for EDs [ 24 ]. In this study, stakeholders were defined as either potential users (patients and caregivers), decision-makers (e.g. health authorities), or facilitators (mental health care professionals, including social workers and nurses). The third group took part in an online survey. The results showed that only 14.6% of the professionals had personal experiences with DMHIs for EDs, less than half had at least looked into such an application, and nearly 30% had never heard of them. However, in-depth insights on the risks and implementation barriers of DMHIs for EDs as expressed by mental health professionals are missing so far, and insights on expectations and potential advantages for ED healthcare are scarce.

This study aims to understand the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs. To what extent do they already use DMHIs in their treatment? Which advantages and chances do they see in their usage? What disadvantages and risks do they perceive? A final focus will be put on specific requirements for the potential integration of digital applications into routine care.

This study used a qualitative research design to investigate the experiences, perspectives, and expectations of mental health professionals for EDs towards DMHIs. Ethical approval was obtained by the Ethics Commission of the Medical Faculty at University of Heidelberg (S-178/2022).

Recruitment and procedures

We invited clinical experts for EDs throughout Germany from inpatient clinics, outpatient clinics, and private practices to take part in a 30–60-min semi-structured telephone interview. Invitations were sent out via e-mail to practitioners with an expertise in the field of EDs. Potential participants were identified both conveniently (i.e. contacts of the authors who fit into the inclusion criteria) and purposively through an internet search process. All participants received written information on the aims and procedures of the study. Informed consent was given electronically and confirmed on the telephone prior to the interviews. The interview guide included questions about previous experience with digital services or programs, advantages and disadvantages, framework conditions and prerequisites, as well as expectations towards an ideal DMHI for EDs. At the beginning of the interviews we explained what kinds of technology might be included in the term DMHI and provided a list with non-exhaustive examples (e.g. online counseling by email or chat; video conferencing; mobile apps; fitness bracelets; online programs; virtual reality). The two interview guides for clinicians in the treatment of children/adolescents and adults are included in Additional files 1 and 2 . Participants received gift vouchers worth 100 Euros for their participation in the qualitative interviews and a subsequent quantitative study. Interviews were conducted between April and July 2022 at the Center for Psychotherapy Research, Heidelberg after interviewer trainings.

Sample description

A total of 24 mental health professionals were included in the study. The age of the participants ranged from 26 to 58 years ( M  = 41.96, SD  = 9.92). Further demographic details are shown in Table  1 .

Data analysis

The duration of the interviews was between 35 and 60 min ( M  = 50′, SD  = 07′). The audio recordings were transcribed verbatim and analyzed by two coders, who were both trained psychologists (GM, DL). The analysis was carried out in MAXQDA [ 25 ].

The analysis followed the rationale of a deductive-inductive content analysis, which combines best practices from two coding techniques [ 26 ] and has as well been indicated as an abductive or complementary approach [ 27 ]. The majority of codes were generated from the material, which refers to inductive coding [ 28 ]. However, some questions directly asked for certain aspects, such as "advantages" or "risks". In these cases, the codes were assigned according to the interview guide. After creating initial codes, all codes were compared and assigned to a coding structure of main codes and subcodes. The two coders, who were both trained psychologists, compared their results in several iterations, refined the coding structure, and agreed on a joint definition in an iterative process. As soon as all codes and subcodes covered the meaning of the data, the decision was made on thematic saturation.

Due to the complexity of the topic, single expressions of the interview partners could be coded with multiple codes and subcodes. By this, nine main codes and subcodes with two levels were assigned to statements of the interview partners (Table  2 ). In the results section details of the codes 4–9 are elaborated. All main codes including the three others, all subcodes, and examples for supporting quotes are provided in Additional file 3 .

Experiences with DMHIs

Even though all participants reported to have some experience with DMHIs, the interviews showed that these referred in most cases to video-based systems during or after the pandemic. Especially therapists for children and adolescents appreciated the opportunity to have a cost-effective way to get in touch with parents in remote areas. Therapists for adults also assessed their experiences as beneficial. However, many interview partners expressed that video-based psychotherapy will never replace a face-to-face therapy. Negative experiences related to patients with a high disease burden and potential suicidality:

‘ …and with the video-based system, I've also had patients who really had a suicidal crisis, who started hurting themselves again, and I would have preferred it if we could have discussed this face-to-face and not through a video-based format ’ (psychological psychotherapist, adult patients, inpatient care, female, 26 years)

Very few professionals reported experiences with specialized DMHIs for EDs. Some of those knew the smartphone application “Recovery Record” [ 29 ] , others mentioned experiences with digital meal records without naming the original title of the app. The experiences with this functionality was perceived as a useful treatment adjunction, as expressed by a therapist for adult patients:

‘ Well, I think I have a pretty good therapeutic relationship with most of the patients. But of course, I've already noticed, like now with this one patient, who is now continuing the meal log, the impression that it gives a lot of security and tends to strengthen the relationship. Yes, now over these eight weeks that she is now inpatient somewhere else ’ (medical doctor, inpatient care and day-care, adult patients, female, 37 years).

Other positive experiences referred to apps providing relaxation or awareness trainings. Skills trainings and psychoeducation were mainly used for patients with obesity. Some participants talked about participating in current studies and made positive statements, e.g. regarding the use of virtual reality for confrontation exercises or training units focusing at the body image.

Advantages and chances

Advantages of DMHIs were categorized in those for patients and those for healthcare provision. Additionally, a few advantages for relatives were mentioned. As a direct advantage for patients, many participants appreciated DMHIs to be an easily accessible, low-threshold way for patients from remote areas or without medical treatment to a first contact with mental healthcare services. Moreover, as many patients feel shame or experience fear of stigma, a DMHI might be a first step for them to access support or ED-related healthcare. In this context, psychoeducation provided in a digital form was seen as beneficial.

Mental health professionals for EDs for children and adolescents observed that many young people spend a lot of time with their mobile devices anyway and could be met by DMHIs where they already are, i.e. in the digital space. Therefore, DMHIs were seen to be close to daily life.

Another aspect mentioned by the participants was that DMHIs might increase treatment adherence, if it targets the individual needs of a patient. This was expressed by a therapist for adults who said:

‘ I could imagine that this aspect of being taken seriously, that this could actually benefit from digital interventions, because what actually happens from time to time, especially when the patients are not very young, when you give them a worksheet or something that sometimes makes them feel like they are in school. So now there is homework, so to say, and I could imagine if you had such an interactive digital tool, and they could do that explained and so that could be a bit catchier. ’ (psychological psychotherapist, outpatient care, adult patients, female, 31 years)

However, other advantages were seen in quality improvements of healthcare by the delivery of DMHIs. As EDs in general are not easy to treat, and some patients do not benefit from psychotherapy, DMHIs could enhance treatment. Beyond that, many patients are in urgent need for psychotherapy but still need to wait several months for treatment. Evidence-based DMHIs for the treatment of EDs would help to reduce this gap:

‘ In general, I would say, first of all that it offers the opportunity to provide much, i.e. better, care. We are now seeing in the aftermath or even during the pandemic that the need has increased enormously, the patients are also significantly sicker, and we cannot respond with a corresponding offer, or even on the contrary, due to illnesses of colleagues and also pandemic-related challenges for the clinics, sometimes the space available is even less, even smaller. And of course, there the use of digital media is a great help in reaching the patients. ’ (Psychological psychotherapist, inpatient care, adolescent patients, female, 41 years)

Disadvantages and boundaries

All participants were aware of risks and limitations of DMHIs for EDs that were grouped as disadvantages for patients and those for healthcare provision. Disadvantages for patients related to issues of data security, lacking personalization, or the fact that DMHIs might not be an adequate and sufficient help. In some cases, the participants even perceived a danger that the disorder itself might worsen.

‘ I would be concerned that it would be too much about, … and then turning in an unhealthy direction, like 'how many calories do I burn' and 'how much do I move' and 'how much do I weigh' . So that's it. Yes, it's also painful for many patients, if it's just about that, I wouldn't expect that from the app, but I don't think that would be good if it's just about weight .’ (psychiatrist for children & adolescents, inpatient care, adolescent patients, female, 38 years)

A major threat for the quality of treatment was seen in the potential impairment of the therapeutic alliance that might occur with DMHIs. On the one hand, concerns were raised that patients might use the DMHI as an insufficient replacement for a face-to-face psychotherapy due to its convenience and comparatively low effort. On the other hand, the physical presence in treatment was seen as a prerequisite for change during therapy. One therapist saw this as crucial for the treatment of patients with AN:

‘ … regular weighing is not something that we completely outsource to the paediatricians, but we weigh them here as well, because weighing is also important for exposure, so that they learn to bear the higher number on the scale. And I think that's something that works better when you're close to it. ’ (Psychological psychotherapist, outpatient care, adult and adolescent patients, female, 47 years)

Furthermore, participants saw the risk that in case of a suicidal crisis or self-harm, the clinician in charge might be informed too late to intervene in time. Even in video-based therapy, this was seen as a major risk, since only parts of the patient are visible for the therapist, not the whole body. Nonverbal communication was regarded as an important element to assess the health status of the patient.

Desired functions and properties

When asked for an ideal DMHI for their patients, all participants expressed their ideas and wishes. These desired functions and properties were grouped into those related to the design of the DMHI, the respective medium (e.g. app, pc), technical functionalities and to the therapeutic content.

The majority of properties wished by the participants aimed at functionalities for mobile applications rather than other devices. In the first line the participants talked about mobile apps for symptom and treatment monitoring. Depending on the respective diagnosis this could be a mood tracking functionality or a meal protocol, that has to be filled out either retrospectively or for future planning. Retrospective protocols were seen as beneficial for analyzing critical situations, e.g. for patients with binge eating episodes. Meal plans were favorized for patients with AN. Other functionalities referred to psychoeducational content or skills training, that could be activated at a specific time point in therapy as suggested by one participant:

‘ Of course, it would be good if the therapist could also simply activate specific topics over the course of the process, so I think that would also be very nice if you noticed: Okay, now self-esteem is somehow a big topic for the patient, then you get in, then you have the option as a therapist to unlock the self-esteem block for the patient, something like that, that would be really cool, well. ’ (Psychological Psychotherapist, outpatient care, adult patients, female, 40 years)

A critical point was the question if the application should allow access for therapists or even relatives. Participants in favor of the opportunity to give therapists access to the content patients had worked on, argued that this would be beneficial for keeping contact with the patients and for sending reminders. However, one therapist insisted that patients should not be able to see when exactly she is available and if a message has already been read, as opposed to text messaging programs. Other mental health professionals appreciated the opportunity to stay in contact with a patient after treatment as a way of digital after-care.

Clinical experts who argued against a shared access said that patients might feel observed and so would not really work on their problems while using the intervention:

‘ I also believe that in case of doubt, depending on the … status in therapy, this changes the benefit and maybe also prevents it, because such a social desirability has a great influence. Well, I think as a patient, if I put my mind to it, I might have situations in which I wouldn't use it, because it would be so uncomfortable that my therapist would see it afterwards. ’ (Psychosomatic medicine (in qualification), day-care, adult patients, female, 40 years)

Most participants argued against an access for relatives to the DMHI of a patient. Exceptions were made in case of video-based therapy, where it was perceived as useful to meet parents at different time points of a psychotherapy. Moreover, separate tools or virtual groups only for relatives of a patient with ED were suggested.

Target groups of DMHIs

The interview partners talked about specific characteristics of the respective target groups of DMHIs in an elaborate and detailed way. In general, a prevalent view was that there would never be a “one-size-fits-all” digital solution for individuals affected by EDs. Some functionalities might be supportive for all kinds of EDs, such as meal records, meal planning, skills training, and planning of activities. But the adequate assignment of ED specific tools that might be available in the future should depend on the age of the patients, the motivation to change, and to a certain extent on the exact diagnosis and comorbidities. Activity planning, for example, might include suggestions for sports and motion for patients with BN and BED, who have to overcome their fears of sports. Patients with AN, in turn, should rather be encouraged to reduce their urge to exercise and do workouts excessively.

Some functionalities could be very helpful for patients with AN, such as assessing the size of meals:

‘ So … what comes to me spontaneously now … patients with anorexia … they often have difficulties when it comes to estimating portion sizes and if there was such an app now, it would take a photo, so to speak, with the camera from your cell phone, if you hold it on the plate and then somehow could compare what would have been, what they should have eaten and what, just then, wouldn't have been. ’ (medical doctor, inpatient and outpatient care, adult patients, female, 43 years)

However, the usefulness of DMHIs for patients with AN was assessed to depend on their current body mass index (BMI). Most concerns were raised against incautiously using DMHIs with those affected by severe AN with a low BMI who were characterized as over-controlling in nearly every aspect related to their illness. One medical doctor even saw the use of digital devices as a root cause for the AN of his patient:

‘ I can think of one patient … you could almost say she became anorexic because of her Apple Watch. And that was a huge act in therapy, that this watch more or less put it down and straightened it and buried it. She's sold it now, I think. This ‘come on, you can still do it’, or this: ‘more exercise, and a little fewer calories today’. And this ‘push, push, push’, that was so extreme. So that was really impressive, she developed a massive anorexia when she bought this smartwatch or she was given it as a gift, because everything just turned around the clock, so to speak. So that was, for me too, really impressive to see. ’ (Medical psychotherapist, inpatient and day-care, adolescent patients, male, 55 years)

For BN and BED, the participants saw more positive opportunities, as these patients were reported to often suffer from shame and fear of stigmatization. For them, according to the mental health professionals for EDs, a DMHI might be a very suitable, low-threshold facilitator to help-seeking. Digital monitoring in bulimic patients was assessed as a great way to analyze potential triggers:

‘ Here, I think, it would also be helpful, for example, to have the opportunity to take a closer look at binge eating afterwards, to analyze it, maybe also via an emotion log, to remember a little bit in which situations it would be helpful maybe helpful strategies to use to avoid binge eating, how, what skills can I use, and so on. ’ (Psychological psychotherapist, inpatient care, adolescent patients, female, 41 years)

Clear contraindications for the use of DMHI were seen in suicidality, severe self-harm and problematic media use (i.e., internet or gaming addiction).

General conditions and requirements

The effective use of DMHIs for the benefit of patients with EDs depends on several general conditions and requirements, as expressed by the interview partners. They observed a broad range of requirements with very different levels of complexity. Many interview partners said that technical requirements, especially in clinical institutions, are often not fully met for the successful integration of DMHIs. As an example, some clinical experts had to use their private mobile phone for a DMHI, even though they would have preferred to be provided with a professional mobile phone. Besides, trained personnel and adequate spaces for their use were mentioned as important conditions. For instance, a separate room for video-based therapy in a multi-person household was viewed as an important prerequisite for patients to ensure privacy.

A major concern focused on data security and privacy, directly followed by a valid legal framework that has to be established, as some professionals feared legal consequences.

‘ From a legal point of view, the issue of data protection is of course a huge issue. So what kind of data do they want to put in there from me, what is done with the data, who gets the data, does the health insurance company get it, is it all stored wonderfully somewhere. So that's a big, big topic. The question of data security and what will happen, millions of data will be generated and what will be done with the data. ’ (Medical psychotherapist, inpatient and day-care, adolescent patients, male, 55 years)

Many interview partners voiced the need for more scientific evidence with specific information regarding treatment mechanisms, indications and contraindications. Nearly all of them felt not to be trained and informed adequately on standards and on the availability of suitable DMHIs.

One main aspect of general conditions and requirements was an appropriate setting for DMHIs. Nearly all participants expressed concerns about DMHIs for unguided self-management. However, as an adjunct to ongoing inpatient or outpatient treatment, the professionals saw many benefits. For example, participants mentioned that inpatient psychotherapy might be accompanied by meal records or daily mood tracking functionalities. Outpatient services could benefit from homework, journal keeping, protocols, and modules for psychoeducation. Moreover, single in-person sessions could be replaced by online sessions, as long as a good therapeutic alliance has been established before.

Finally, many participants saw benefits in the delivery of a digital aftercare tool in order to stay in contact to patients and build on therapy successes. One expert gave an example:

‘ Then actually after the inpatient stay, … seeing something to prevent relapse in the sense that they might have a kind of traffic light system, am I still running in the green, is it running in the yellow area, I'm already in the red area. As far as symptom behavior is concerned, I could well imagine that too. So how's it going with eating, exercise, decrease in vomiting if that's an issue now, or binge eating. ’ (Psychological psychotherapist, outpatient and day-care, adult patients, female, 55 years)

This qualitative interview study asked mental health professionals for their experiences, perspectives, and expectations regarding DMHIs for EDs. In general, our results show that the ED professionals voice open-minded but critical attitudes on the integration of DMHIs for their patients. This general attitude was independent of professionals’ training in either working with children and adolescents or adults. However, only few clinical experts reported having prior experiences with DMHIs during the pandemic aside from video-based therapy.

All professionals talked about various advantages and disadvantages. Moreover, they were asked about useful technologies and functionalities, they would benefit from if they were available. In the following two sections we give an overview on specific requirements of the future integration of DMHIs in routine care in the context of the current literature. Our considerations first relate to different areas of the healthcare spectrum and are then grouped by diagnosis.

Requirements for the integration of DMHIs into different areas of the healthcare spectrum

DMHIs for EDs may potentially be used across all areas from prevention, self-management, and treatment to aftercare. Mental health professionals in our interviews saw the greatest potential in the delivery of digitally-enhanced outpatient care, i.e. DMHIs as adjunct to conventional psychotherapy. In this context, the most important aspect was that DMHIs were assumed to be useful as soon as a positive therapeutic alliance has been established. In fact, the alliance has been shown to be an important factor in internet-based interventions for mental disorders in a meta-analysis of 18 studies [ 30 ]. Only few studies investigated the role of the alliance in DMHIs specific for EDs. In the Dutch program “Look at your eating” (Etendebaas) the therapeutic alliance was predictive for pathology and treatment completion [ 31 ]. However, psychotherapy research has also shown that the relationship between the therapeutic alliance and treatment outcome is bidirectional, i.e. early symptom improvement predicts subsequent improvements in the alliance and vice versa [ 32 ]. In line with this, the alliance with the therapist accompanied by the confidence in the own ability to change can be improved by the supportive use of DMHIs in addition to outpatient care [ 33 ]. Outpatient care, in turn, plays a major role in the promotion of access to DMHIs. A recent study of Dahlhausen et al. showed that especially clinicians in outpatient settings are more able to promote adherence to DMHIs than those in hospitals, because of the long-lasting relationships they have with their patients [ 23 ]. To sum up, clinicians see the therapeutic alliance as a facilitator for the integration of DMHIs into routine care and results from the literature support this assessment. This is as well supported by the observation that the clinicians are the gatekeepers of patients’ access to DMHIs [ 20 ]. When asking for the perspective of individuals with EDs or ED symptoms, studies asking directly for their opinion regarding the alliance are missing so far. However, a randomized controlled study showed that increased therapist support increases satisfaction of individuals with ED symptoms but not symptom improvement [ 34 ]. However, users clearly prefer clinician support in DMHIs [ 35 ].

Unguided self-management applications were rated critically by the participants of our study. However, the interview partners saw potential of DMHIs in bridging waiting times, as already reported in previous studies [ 24 ]. Skeptical voices added that there might be disappointments especially in young people and their relatives if DMHIs would not lead to an immediate improvement of symptoms. There could be the risk that these people might give up and miss a timely intervention.

Evidence on self-help interventions has been established mostly for mental disorders other than ED, e.g. in the case of depression [ 36 ], anxiety [ 37 ], and obsessive–compulsive disorder [ 38 ] usually by comparing a DMHI to a wait-list or usual care, which is not necessarily an evidence-based face-to-face psychotherapy. While many studies have confirmed the potential of self-management programs for ED prevention (i.e. in at-risk samples) or in self-selected samples with no diagnostic procedures, the body of literature on high-quality RCTs providing evidence on self-management interventions for individuals with diagnosed ED is still small [ 12 , 13 , 39 ]. Although patient engagement was high in a the case of a platform for BED [ 40 ], internet-based self-help was inferior to face-to-face but still effective for BED [ 41 ], and online CBT-based self-help showed good clinical outcomes for patients with BN [ 42 ]. There is evidence that such DMHIs are better than no intervention (e.g. when compared to waitlist groups), but not superior to other active conditions (e.g. when compared to bibliotherapy [ 43 ]) and inferior to conventional psychotherapy [ 41 ]. Recommendations concerning DMHIs should therefore take the respective context into account and their use may be well-justified in cases where no timely conventional treatment is available.

DMHIs for EDs can as well be a useful adjunct for day-care, where patients stay in the hospital during the day, but go home for the night. According to the mental health professionals in our study, such partially inpatient treatment for patients with EDs could benefit from mobile monitoring or digital homework. A study on digitally supported daycare for patients with EDs was carried out during the pandemic. Telemedicine with remote sessions was delivered for a small number of adolescent patients with AN. The concept was successful in case there was a supporting family structure [ 44 ].

Finally, aftercare was considered a highly promising setting for the integration of DMHIs, as at this point in therapy a certain mental stability of the patient already can be assumed. Nevertheless, an effective strategy for relapse prevention is needed and here, DMHIs show potential. Although the evidence regarding the effectiveness of digital aftercare is limited and heterogeneous, there are positive results for BN [ 45 ]. Another study with patients with binge eating attacks tested an aftercare DMHI. They showed that improvements were observed mainly in those patients, who still suffered from their attacks after hospital discharge [ 46 ]. In the case of AN, symptom improvements could be shown as well [ 47 ], however, more recent results with current technological advancements are needed.

In summary, the main prerequisite for the integration of DMHIs into conventional healthcare is the definition of the most suitable care settings. According to our findings, these are outpatient treatment, daycare, and aftercare. Outpatient treatment, supported by DMHIs can take several forms, of which a blended care concept is an approach that covers both, conventional, face-to-face psychotherapy and internet-based support by a DMHI. Another model is stepped care, that can either follow a stepping-up approach, i.e. by integrating DMHIs in a very early stage of treatment and by this, preventing symptoms, or a stepping-down concept, that means that a conventional treatment is followed by a DMHI, in order to stabilize treatment success [ 48 ]. Both concepts depend on the respective clinical setting to a certain extent. Randomized controlled designs on aftercare by DMHIs show improvements, however, they remain statistically not significant regarding the main outcome of ED symptomatology at follow-up [ 12 ]. Nevertheless, patients with ED appreciated the opportunity to use a DMHI after discharge and showed high adherence [ 49 ]. Stepped care supported by DHMIs in general reached a high level of acceptability by mental health professionals treating patients with EDs [ 50 ]. Beyond this, the necessary legal (accountability, data protection), financial (reimbursement), and technical barriers have to be considered (e.g., spatial resources or devices for therapists, who do not want to use their private mobile phones for treatment).

Requirements of DMHIs for specific types of EDs

Several requirements for DMHIs emerged regarding specific ED diagnoses. A survey with community-based participants from the general public, in parts suffering from symptoms of BN or BED, revealed that the majority preferred a generic e-health program for any kind of ED over a specific one [ 35 ]. The mental health professionals in our study had another view on this topic. While they agreed on many common suitable DMHI modules for all EDs, such as psychoeducation, homework, relaxation, and skills training, some specific functionalities were discussed with respect to the specific ED diagnosis.

Especially with regard to the high urge to exercise that can be observed in some AN patients on the one hand, and avoidance of exercise in some BN or BED patients on the other hand, DMHIs should provide personalized suggestions with respect to individual needs. Moreover, even if meal records were favored for any kind of ED, the assessment of meal portions/ sizes by a mobile app were seen as much more relevant for patients with AN. Apart from that, it would be useful for patients with BN or BED to find out potential triggers for a binge eating episode by journal keeping and mood tracking.

The review of Linardon et al. [ 13 ] concluded that, based on 8 treatment-focused randomized-controlled trials, the evidence of DMHIs is stronger for BN than BED, and very limited for AN. The authors argue, that this may be due to concerns that the severity of the condition in AN leads therapists to prioritize intensive face-to-face treatment for these patients. The professionals in our study argued in a very similar way against the use of DMHIs in severe cases of AN, as DMHIs might be triggering, and encourage over-controlling eating behavior in patients. Moreover, a very low BMI might have a negative impact on cognitive functioning and concentration. Patients with AN were further seen as the patient group with a higher need for support in comparison to patients with BN and BED, who don’t need the same care frequency than patients with AN. This result corresponds to the known burden of disease and mortality rates in AN [ 2 ].

Strengths and limitations

To the best of our knowledge, this is the first study that conducted detailed qualitative interviews with mental health professionals for EDs for both, children and adolescents, and adult patients in Germany on their attitudes and experiences regarding DMHIs. However, our study is limited to the healthcare system in Germany and comparisons at an international level remain limited. Moreover, DMHIs were defined very broadly in our interviews, as all types of interventions, such as mobile apps, virtual reality interventions, or online programs were included. Due to the qualitative approach, we were not able to ask for specific facilitators, barriers and obstacles for all types of interventions with regard to the respective types of EDs in a systematic way. As a consequence, important factors specific for single types of interventions, e.g. barriers for the implementation of mobile apps for BN patients, implementation of virtual reality for AN patients etc. may have been overseen. As current technology advancements are rapidly developing and by this reaching a high level of specificity, future research designs should focus on single technologies with their specific barriers and facilitators for the whole diagnostic spectrum of EDs.

Mental health professionals for EDs show positive attitudes towards DMHIs. However, only few of them already had experiences with DMHIs in their daily practice. Main barriers to DMHI integration refer to legal aspects, data protection regulations, and the quality of technical equipment in clinics or outpatient wards. According to our participants, the use of DMHIs has high potential as an adjunct to outpatient treatment or in aftercare, but not as stand-alone self-management interventions, that individuals with EDs would use independent of conventional psychotherapy. Clinical experts saw helpful functionalities for all types of EDs, however, single modules should be tailored to the needs of AN, BN, and BED. Targeted DMHIs for specific diagnoses of AN, BN, and BED are needed and appropriate especially for concepts of blended care.

Contributions to the literature

This study presents results of qualitative interviews with mental health experts for eating disorders who were asked on their views on the implementation of digital mental health interventions (DMHIs) for their patients.

Mental health professionals see potential for the use of DMHIs in outpatient care and in aftercare, but risks in case of severe anorexia and suicidality.

A stable therapeutic alliance is an important prerequisite for the successful integration of DMHIs into care.

Many therapists do not feel informed in a sufficient way on evidence base and regulations.

Reporting standards

The COREQ criteria for reporting qualitative research were followed [ 51 ]. The checklist helped to clarify the procedures, analysis, and interpretation.

Availability of data and materials

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

Abbreviations

Anorexia nervosa

Binge eating disorder

Bulimia nervosa

Digital mental health intervention

Eating disorder

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Acknowledgements

We thank our interview partners for their willingness to share their time with us for the benefit of our research aims.

Open Access funding enabled and organized by Projekt DEAL. The author(s) disclose the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Bundesministerium für Gesundheit on the basis of a resolution of the German Bundestag by the Federal Government. Moreover, we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding program Open Access Publishing, by the Baden-Württemberg Ministry of Science, Research, and the Arts, and by Ruprecht-Karls-Universität Heidelberg.

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Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany

Gwendolyn Mayer, Ina Michelsen & Hans-Christoph Friederich

Center for Psychotherapy Research, Heidelberg University Hospital, Bergheimer Str. 54, 69115, Heidelberg, Germany

Diana Lemmer, Pauline Schrader & Stephanie Bauer

German Center for Mental Health (DZPG), partner site Mannheim/Heidelberg/Ulm, Germany

Hans-Christoph Friederich & Stephanie Bauer

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Contributions

SB conceptualized the study. SB and HCF contributed to the grant application. SB, HCF, GM, and DL were contributing to the design of the study. GM wrote the original drafts for both this manuscript and the interview guide, while SB, HCF, DL, IM, and PS participated in further reviewing, guidance, and/or editing. Interviews were conducted by IM, PS, and DL. IM and PS transcribed the interviews. GM and DL analyzed the data.

Corresponding author

Correspondence to Gwendolyn Mayer .

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Ethics approval and consent to participate.

Ethical approval was obtained by the Ethics Commission of the Medical Faculty at University of Heidelberg (S-178/2022). Prior to their participation, participants were informed via e-mail and online on the study website about the nature and scope of the study, particularly about the potential benefits and risks. They had the opportunity to contact us for further clarification. Each participant received a personal study code, which they could input on our study website to obtain detailed study information and for informed consent. The consent of the participants was documented through a mandatory input field for electronic confirmation of consent (participation and data protection declaration). The participation information was accessible online at any time during the study period on the project website ( https://www.sida-essstoerungen.de/sidaess/ ). Consent was additionally obtained at the beginning of each interview, prior to recording. Both online and telephone consent were mandatory for participation.

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Supplementary Information

Additional file 1. .

Interview guidelines for experts in the treatment of children and adolescents with eating disorders.

Additional file 2. 

Interview guide for experts in the treatment of adult patients with eating disorders.

Additional file 3. 

Summary of the main codes in alphabetic order used for qualitative analysis with their subcodes and supporting quotes.

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Mayer, G., Lemmer, D., Michelsen, I. et al. Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study. J Eat Disord 12 , 32 (2024). https://doi.org/10.1186/s40337-024-00978-1

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Published : 23 February 2024

DOI : https://doi.org/10.1186/s40337-024-00978-1

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  • Mental health care
  • Eating disorders
  • Qualitative research
  • Implementation barriers
  • Implementation facilitators
  • Digital mental health

Journal of Eating Disorders

ISSN: 2050-2974

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