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Writing Research Papers

• Writing a Literature Review

When writing a research paper on a specific topic, you will often need to include an overview of any prior research that has been conducted on that topic.  For example, if your research paper is describing an experiment on fear conditioning, then you will probably need to provide an overview of prior research on fear conditioning.  That overview is typically known as a literature review.  

Please note that a full-length literature review article may be suitable for fulfilling the requirements for the Psychology B.S. Degree Research Paper .  For further details, please check with your faculty advisor.

Different Types of Literature Reviews

Literature reviews come in many forms.  They can be part of a research paper, for example as part of the Introduction section.  They can be one chapter of a doctoral dissertation.  Literature reviews can also “stand alone” as separate articles by themselves.  For instance, some journals such as Annual Review of Psychology , Psychological Bulletin , and others typically publish full-length review articles.  Similarly, in courses at UCSD, you may be asked to write a research paper that is itself a literature review (such as, with an instructor’s permission, in fulfillment of the B.S. Degree Research Paper requirement). Alternatively, you may be expected to include a literature review as part of a larger research paper (such as part of an Honors Thesis). 

Literature reviews can be written using a variety of different styles.  These may differ in the way prior research is reviewed as well as the way in which the literature review is organized.  Examples of stylistic variations in literature reviews include: 

• Summarization of prior work vs. critical evaluation. In some cases, prior research is simply described and summarized; in other cases, the writer compares, contrasts, and may even critique prior research (for example, discusses their strengths and weaknesses).
• Chronological vs. categorical and other types of organization. In some cases, the literature review begins with the oldest research and advances until it concludes with the latest research.  In other cases, research is discussed by category (such as in groupings of closely related studies) without regard for chronological order.  In yet other cases, research is discussed in terms of opposing views (such as when different research studies or researchers disagree with one another).

Overall, all literature reviews, whether they are written as a part of a larger work or as separate articles unto themselves, have a common feature: they do not present new research; rather, they provide an overview of prior research on a specific topic . 

How to Write a Literature Review

When writing a literature review, it can be helpful to rely on the following steps.  Please note that these procedures are not necessarily only for writing a literature review that becomes part of a larger article; they can also be used for writing a full-length article that is itself a literature review (although such reviews are typically more detailed and exhaustive; for more information please refer to the Further Resources section of this page).

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible.  You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it.  At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a literature search.

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles.  You should focus on peer-reviewed, scholarly articles.  Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research.  Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed.  For more information about this step, please see the Using Databases and Finding Scholarly References section of this website.

3. Read through the research that you have found and take notes.

Absorb as much information as you can.  Read through the articles and books that you have found, and as you do, take notes.  The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information).  Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources ; and some sources may refer to yet other sources of potential interest.  This is often the most time-consuming part of the review process.  However, it is also where you get to learn about the topic in great detail.  For more details about taking notes, please see the “Reading Sources and Taking Notes” section of the Finding Scholarly References page of this website.

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself.  However, it is often helpful to first reflect on all the reading that you have done.  What patterns stand out?  Do the different sources converge on a consensus?  Or not?  What unresolved questions still remain?  You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review.  Are you going to summarize or critically evaluate?  Are you going to use a chronological or other type of organizational structure?  It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing.  When writing, keep in mind that literature reviews are generally characterized by a summary style in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves).  However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was).   After you have written a first draft, you should read it carefully and then edit and revise as needed.  You may need to repeat this process more than once.  It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft.

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper).  Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

Further Tips for Writing a Literature Review

Full-length literature reviews

• Many full-length literature review articles use a three-part structure: Introduction (where the topic is identified and any trends or major problems in the literature are introduced), Body (where the studies that comprise the literature on that topic are discussed), and Discussion or Conclusion (where major patterns and points are discussed and the general state of what is known about the topic is summarized)

Literature reviews as part of a larger paper

• An “express method” of writing a literature review for a research paper is as follows: first, write a one paragraph description of each article that you read. Second, choose how you will order all the paragraphs and combine them in one document.  Third, add transitions between the paragraphs, as well as an introductory and concluding paragraph. 1
• A literature review that is part of a larger research paper typically does not have to be exhaustive. Rather, it should contain most or all of the significant studies about a research topic but not tangential or loosely related ones. 2   Generally, literature reviews should be sufficient for the reader to understand the major issues and key findings about a research topic.  You may however need to confer with your instructor or editor to determine how comprehensive you need to be.

Benefits of Literature Reviews

By summarizing prior research on a topic, literature reviews have multiple benefits.  These include:

• Literature reviews help readers understand what is known about a topic without having to find and read through multiple sources.
• Literature reviews help “set the stage” for later reading about new research on a given topic (such as if they are placed in the Introduction of a larger research paper). In other words, they provide helpful background and context.
• Literature reviews can also help the writer learn about a given topic while in the process of preparing the review itself. In the act of research and writing the literature review, the writer gains expertise on the topic .

Downloadable Resources

• How to Write APA Style Research Papers (a comprehensive guide) [ PDF ]
• Tips for Writing APA Style Research Papers (a brief summary) [ PDF ]
• Example APA Style Research Paper (for B.S. Degree – literature review) [ PDF ]

Further Resources

How-To Videos     

• Writing Research Paper Videos
• UCSD Library Psychology Research Guide: Literature Reviews

External Resources

• Developing and Writing a Literature Review from N Carolina A&T State University
• Example of a Short Literature Review from York College CUNY
• How to Write a Review of Literature from UW-Madison
• Writing a Literature Review from UC Santa Cruz  
• Pautasso, M. (2013). Ten Simple Rules for Writing a Literature Review. PLoS Computational Biology, 9 (7), e1003149. doi : 1371/journal.pcbi.1003149

1 Ashton, W. Writing a short literature review . [PDF]     

2 carver, l. (2014).  writing the research paper [workshop]. , prepared by s. c. pan for ucsd psychology.

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What is a Literature Review?

Description.

A literature review, also called a review article or review of literature, surveys the existing research on a topic. The term "literature" in this context refers to published research or scholarship in a particular discipline, rather than "fiction" (like American Literature) or an individual work of literature. In general, literature reviews are most common in the sciences and social sciences.

Literature reviews may be written as standalone works, or as part of a scholarly article or research paper. In either case, the purpose of the review is to summarize and synthesize the key scholarly work that has already been done on the topic at hand. The literature review may also include some analysis and interpretation. A literature review is  not  a summary of every piece of scholarly research on a topic.

Why are literature reviews useful?

Literature reviews can be very helpful for newer researchers or those unfamiliar with a field by synthesizing the existing research on a given topic, providing the reader with connections and relationships among previous scholarship. Reviews can also be useful to veteran researchers by identifying potentials gaps in the research or steering future research questions toward unexplored areas. If a literature review is part of a scholarly article, it should include an explanation of how the current article adds to the conversation. (From: https://researchguides.drake.edu/englit/criticism)

How is a literature review different from a research article?

Research articles: "are empirical articles that describe one or several related studies on a specific, quantitative, testable research question....they are typically organized into four text sections: Introduction, Methods, Results, Discussion." Source: https://psych.uw.edu/storage/writing_center/litrev.pdf)

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible.  You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it.  At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a Literature Search

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles.  You should focus on peer-reviewed, scholarly articles . In SuperSearch and most databases, you may find it helpful to select the Advanced Search mode and include "literature review" or "review of the literature" in addition to your other search terms.  Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research.  Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed. Most of the databases you will need are linked to from the Cowles Library Psychology Research guide .

3. Read through the research that you have found and take notes.

Absorb as much information as you can.  Read through the articles and books that you have found, and as you do, take notes.  The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information).  Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources; and some sources may refer to yet other sources of potential interest.  This is often the most time-consuming part of the review process.  However, it is also where you get to learn about the topic in great detail. You may want to use a Citation Manager to help you keep track of the citations you have found. 

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself.  However, it is often helpful to first reflect on all the reading that you have done.  What patterns stand out?  Do the different sources converge on a consensus?  Or not?  What unresolved questions still remain?  You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review.  Are you going to summarize or critically evaluate?  Are you going to use a chronological or other type of organizational structure?  It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing.  When writing, keep in mind that literature reviews are generally characterized by a  summary style  in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves).  However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was).   After you have written a first draft, you should read it carefully and then edit and revise as needed.  You may need to repeat this process more than once.  It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft. (note: this step is only if you are using the literature review to write a research paper. Many times the literature review is an end unto itself).

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper).  Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

These steps were taken from: https://psychology.ucsd.edu/undergraduate-program/undergraduate-resources/academic-writing-resources/writing-research-papers/writing-lit-review.html#6.-Incorporate-the-literature-r

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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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Psyc 2305 - introduction to research methods in psychology.

• Develop a Topic
• Conduct a Literature Review
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What is a Literature Review?

If this is your first time having to do a literature review, you might be wondering what a "literature review" actually is. This page will help you gain a better understanding of what a literature review is, why it is helpful to do one, and how you might go about it. Watch the following video to start learning more.

Video Transcript

Beginning Your Search

Once you have refined your topic into a proper research question, you can begin your search for your literature review. The first step in this process is deciding where is the best place for you to search to find the information that you need. The following video explains the difference between what you can find with Google and what you can find in the libraries' research databases.

Ultimately, because you are primarily searching for academic literature related to your research topic in psychology, you'll mostly be looking in the libraries' research databases. The following databases are a good place to start to find scholarly articles and other research literature that might relate to your topic for PSYC 2305. Read the database descriptions to decide which are the most appropriate databases for you to search in.

• APA PsycInfo This link opens in a new window APA PsycInfo, American Psychological Association’s (APA) renowned resource for abstracts of scholarly journal articles, book chapters, books, and dissertations, is the largest resource devoted to peer-reviewed literature in behavioral science and mental health.

• ERIC (EBSCOhost) This link opens in a new window ERIC, the Educational Resource Information Center, provides access to education literature and resources.
• MEDLINE (EBSCOhost) This link opens in a new window MEDLINE provides scholarly information on medicine, nursing, the health care system, biomedical sciences, and much more.
• Web of Science This link opens in a new window Web of Science is a comprehensive research platform for finding journal articles, patents, and conference proceedings in a wide range of disciplines. The content is highly curated.

Searching in Databases

As you start to search in library databases, you’ll be making use of search terms to help you find what you need. Keep in mind that when you want to do a narrower, more focused search that gives you highly relevant results, you will want to combine multiple search terms or phrases. The downside of this approach can be that you may only get a few results or none at all. When combining search terms, you will need to be careful about which words you combine, how many you use, and how you combine them. It’s generally best practice to keep it limited to 2 to 4 words or phrases. The important thing to remember is that a literature search is an iterative process.   Expect yourself to test different search terms back and forth a couple of times in different databases.

Watch the following video to learn more about developing effective search terms:

If you want to learn more about developing search terms and other search strategies that will help you find the information you need, you can complete the Search Terms and Strategies online lesson, or use the worksheet to guide your process.

• Search Terms and Strategies lesson
• Search Terms and Strategies worksheet
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2 A History of Clinical Psychology

Donald K. Routh Department of Psychology University of Miami Miami, FL, USA

• Published: 18 September 2012
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To be memorable, a history such as this might best be organized under a small number of headings. Accordingly, this chapter is structured around the work of seven pioneers who arguably had the greatest influence on the development of the field. Lightner Witmer is generally considered to have founded clinical psychology in 1896 (McReynolds, 1987, 1997; Routh, 1996; Watson, 1956). Hippocrates was the ancient Greek founder of medicine, always a close professional cousin of clinical psychology and a scientific model for psychology in general. Theodule Ribot led the development of psychology as an academic discipline in 19th-century France, as one primarily focused on clinical issues. Alfred Binet, also in France, devised the first practical “intelligence” test in 1905; administering such tests was among the most common activities of early clinical psychologists. Leta Hollingworth was an early practitioner who played a large role in the development of organized clinical psychology beginning in 1917 (Routh, 1994). Sigmund Freud founded psychoanalysis, the first influential form of psychotherapy practiced by clinical psychologists, among others. Finally, Hans Eysenck was among the earliest to conceptualize behavior therapy and to promote the use of what have come to be known as evidence-based methods of intervention in clinical psychology.

Clinical psychologists have become familiar figures in America and in many countries around the world (Swierc & Routh, 2003 ). Indeed, clinical work now seems to be the most common activity of psychologists. They carry out psychotherapy or other interventions with individuals, groups, and families. They engage in various kinds of clinical assessment of the mental and behavioral aspects of health problems. Many collaborate with other health professionals or act as consultants in clinics and hospitals. Clinical psychologists are frequently involved in educational activities, teaching in colleges or universities, and many are also engaged in research. Despite its familiarity, this field had its origins in 1896, not much more than a century ago. This chapter attempts to provide a vivid portrait of its roots.

Hippocrates

To speak of “clinical” psychology is to invoke the medical metaphor of care at the bedside of the individual (the Greek word klinein refers to a couch or bed). In naming clinical psychology, Lightner Witmer thus alluded to the tradition of Hippocrates. Born on the Greek island of Cos about 460 bce , Hippocrates is considered to be the founder of medicine. In using the word “clinical,” Witmer implied that it is appropriate for psychology, like medicine, to attempt to help individuals.

Medicine is not only a profession but also a scientific field and, as such, served as a model for psychology in general. In comparing the Hippocratic writings to the previous Greek tradition of the god Asclepias, the most notable characteristic is Hippocrates’ naturalism, the idea that the phenomena of human illnesses can be understood and explained in scientific terms. A famous example concerns epilepsy, often labeled in ancient Greece as a “sacred” disease. Seizures were thus explained as possession of the body by some invisible spirit. In contrast, Hippocrates and his followers believed that epilepsy was no more divine than any other illness and that its causes could be understood in natural terms (Temkin, 1994 ).

In addition to the name of Hippocrates, so familiar to accounts of Western medicine, the origins of modern scientific medicine can also be traced to various sources outside Europe, for example, ancient China, India, Egypt, and various smaller indigenous groups. In China, the best known ancient source of medical wisdom is the Yellow Emperor’s Classic of Internal Medicine , probably written in the late first century bce . This book discusses such well-known concepts as yin and yang; the Five Elements; the effects of diet, lifestyle, emotions, and the environment on health; how diseases develop; and the principles of acupuncture (Veith, 2002 ).

In ancient India, Ayurvedic medicine evolved over several millennia and appeared in writing about 2,000 years ago. The Sanskrit term, ayur means “life,” and the term veda , “science or knowledge.” The Ayurveda describes the constitution of the body ( prakriti ) and the operation of life forces ( doshas ), made up of the elements ether, air, fire, water, and earth. Ayurvedic treatments rely heavily on the use of herbs and plants (Lodha & Bagga, 2001).

Our knowledge of ancient Egyptian medicine is fragmentary. Examples of well-known sources include the Edwin Smith Papyrus and the Ebers Papyrus. The Edwin Smith Papyrus was written in about the 16th century bce , based on material from perhaps a thousand years earlier. It outlines a series of 48 traumatic injury cases, including a discussion of the physical examination, treatment, and prognosis of each. Of special interest to psychologists are its descriptions of the cranial sutures, meninges, external surface of the brain, cerebral spinal fluid, and existence of a pulse in cerebral blood vessels (Breasted, 1922 ). The Ebers Papyrus, written in about 1550 bce , includes a description of mental disorders, including depression and dementia. Like Hippocrates, the ancient Egyptians seemed to think of mental and physical disorders in much the same terms.

It seems that the culture of just about every human group includes concepts of health and illness, including what psychologists consider to be mental disorders, as well as ideas about how these problems should be managed. The Florida Seminole tribe, to give a modern example, considers the role of its medicine people an important one, which requires about eight years of intensive training to master and requires extensive knowledge of herbal treatments (West, 1998 ).

Many of the founders and influential researchers in the modern academic discipline of psychology, including Wilhelm Wundt, William James, Hermann Helmholtz, and Ivan Pavlov, were physicians by education, but they were scientists and scholars rather than practitioners of medicine. Wilhelm Wundt (Witmer’s teacher at the University of Leipzig), who is generally credited with founding the first psychology laboratory in 1879, was medically trained, but not a practicing physician. Wundt carried out research in psychology, edited a journal, wrote books summarizing research in the field, and trained many of the first generation of experimental (or “physiological”) psychologists, including Americans as well as Europeans (Benjamin, Durkin, Link, Vestal, & Accord, 1992 ). Although he was primarily devoted to basic research in psychology, Wundt maintained an interest in what today might be called mental health issues. Among Wundt’s students and research collaborators was Emil Kraepelin, one of the leading psychiatrists of Germany during the late 19th and early 20th centuries (Kraepelin, 1962 ). Kraepelin studied manic-depressive disorder and conceptualized “dementia praecox” (the mental disorder now termed schizophrenia). He established psychology laboratories in mental hospitals under his direction, and studied experimentally the effects of alcohol and morphine on human reaction time.

William James, who is considered to be the founder of modern psychology in the United States, was also trained as a physician, but chose not to practice medicine. James spent his career teaching physiology, psychology, and philosophy at Harvard University, and wrote the classic two-volume textbook on The Principles of Psychology (James, 1890 ). Like Wundt, James maintained an academic interest in what we would now call mental health, as manifested by his 1896 Lowell Lectures on Exceptional Mental States (Taylor, 1983 ).

Another example of the influence of medicine on general psychology is provided by the work of Hermann Helmholtz. Helmholtz was born in Prussia in 1821, and he went on to become a world-recognized figure in several scientific fields, including physics, physiology, medicine, and psychology (Cahan, 1993 ). In terms of contributions to psychology and what is now called neuroscience, Helmholtz was the first to actually measure the speed of the nerve impulse in several different species. Some of his best-known scientific work on vision and hearing utilized his background in several areas, including mathematics, physics, physiology, and psychology. What is known as the Young-Helmholtz theory of color vision hypothesized the existence of three separate types of receptors in the retina for light of different wavelengths, corresponding to red, green, and violet. Subsequent research indeed demonstrated three different types of cone cells in the retina, with visual pigments responding to different wavelengths. In terms of the functioning of the auditory system, Helmholtz believed that the cochlea, the main sensory organ of the inner ear, worked something like a piano, with different strings vibrating to different frequency in sounds transmitted to it. Helmholtz also developed a theory of visual perception as an empirical process—in other words, one developed through experience. According to this theory, which continues to be influential, people engage in “unconscious inferences” in order to combine various cues about how far away objects are. During his time as a professor of physiology at the University of Heidelberg, Helmholtz served as supervisor to a younger colleague named Wilhelm Wundt. Thus, in effect, he taught some experimental psychology to the man who later became known as its “founder.”

A final example of the influence of medicine on general psychology is provided by the career of the Russian scientist, Ivan Pavlov, who received the Nobel Prize for Medicine or Physiology in 1904, for his work on digestive processes. Born in 1849, Pavlov attended what was then called the Medical-Surgical Academy in St. Petersburg, the leading medical school of Russia. Rather than going into medical practice, though, Pavlov spent his career as a researcher. He developed a special chronic physiological procedure, isolating a separate pouch within a dog’s stomach so that digestive juices could be collected from it. He was thus able to carry out a systematic program of research on the neural control of digestive processes in the dog. His laboratory worked out an arrangement in which about 15 medical students at a time seeking doctoral degrees could be employed as research collaborators, a veritable factory of physiologists (Todes, 2002 ). By about 1902, even before he received the Nobel Prize, Pavlov had decided to change the overall direction of his research toward work on what became known as “conditioned reflexes.” Thus, he began what the world came to recognize as pioneering research in experimental psychology. Like humans and other animals, dogs do not just salivate when they actually eat, but as a result of just smelling the food, looking at it in a dish, or the appearance in the room of the person who is about to feed them. Pavlov used salivation to study processes now familiar to all psychologists, including conditioning, extinction, generalization, discrimination, and many others, including the disturbed behaviors called “experimental neuroses” that can be observed in the laboratory setting. His Lectures on Conditioned Reflexes were translated into English in 1927, and the concepts of conditioning have been influential throughout the world since that time.

Unquestionably, the psychological research of scientists such as Helmholtz and Pavlov has great “clinical” relevance, for example in ophthalmology and gastroenterology, but these workers are not usually regarded as clinical psychologists, because their work was not directly concerned with mental health, and they were not directly involved in trying to help individuals.

Theodule Ribot

Although clinical psychology as such did not originate there, France had a central role in the development of both psychiatry and neurology. French psychology, when it did develop under the leadership of Theodule Ribot (1839–1916), had its principal focus on the study of psychopathology (Nicolas & Murray, 1999 ). The French physician Philippe Pinel is generally considered to be the father of psychiatry as a medical specialty (Riese, 1969 ). Not long after the French Revolution of 1789, Pinel joined Jean-Baptiste Pussin in removing the chains from the mental patients in the Bicetre and Salpetriere hospitals in Paris. During the 19th century, the eminent neurologist Jean Charcot also worked at the Salpetriere Hospital, where he pioneered in the use of hypnosis in the treatment of patients with “hysteria” (Guillain, 1959 ). Ribot, the founder of French psychology, had Charcot as one of his teachers.

Ribot wrote an influential book about what was happening in psychology in Germany and England, and founded a journal to introduce his French colleagues to the psychological research going on in these countries. In 1881, Ribot published a second book, Disorders of Memory . Summarizing the existing research on memory, he developed the generalization now known as “Ribot’s Law,” stating that, in retrograde amnesia associated with brain damage, it is the most recent memories that tend to be lost, sparing the older ones. In some of his other writings, Ribot described the phenomenon of anhedonia , a loss of pleasure in daily activities, which is typical of persons experiencing mental depression and schizophrenia. In 1885, Ribot was made professor of psychology at the Sorbonne, and in 1888, he was given a chair in experimental and comparative psychology at the prestigious College de France.

The pattern in France was for any psychologist who wished to provide clinical services to individuals to go to medical school and become a neurologist or psychiatrist. Thus, Pierre Janet did his dissertation in psychology in 1889, under Ribot, and then completed a medical thesis under Charcot in 1892, on the mental states of persons with hysteria. It was Janet who coined the term “dissociation,” and who first described multiple personality disorder. He also described “psychasthenia,” better known today as obsessive-compulsive disorder. In addition, Janet developed a variety of psychotherapy techniques, considered by some to be an important rival of Freud’s psychoanalysis (Janet, 1924 ).

Lightner Witmer

The term “clinical psychology” was first used in an article by Lightner Witmer (1867–1956), a psychology professor at the University of Pennsylvania, in the inaugural issue of a new journal he began to publish in 1907, The Psychological Clinic . Its 19th-century founders considered the modern discipline of psychology to be a science analogous to physiology; indeed, it was often labeled as “physiological psychology” for that reason. Witmer’s idea was simply that if this new science was worthwhile, it ought to be possible to use its principles to help individuals with various problems. In other words, he thought that psychology should be an area of professional practice, as well as a science, and history has vindicated this concept.

The work of Witmer had some of its roots in France, but not in the work of Ribot or Janet. Witmer was most interested in the attempts of J. R. Pereira and J. M. Itard to teach language to nonverbal children, including the so-called Wild Boy of Aveyron, and the procedures developed by Edouard Seguin to remediate children with intellectual disabilities (Routh, del Barrio, & Carpintero, 1996 ).

Before going into psychology, Witmer taught English in a Philadelphia preparatory school (McReynolds, 1997 ). As a teacher, he encountered a student who was progressing poorly in his schoolwork. Witmer tried to help the youngster overcome these academic problems and learned that the boy had specific difficulty with language, including speaking and reading. The boy seemed to benefit from Witmer’s efforts in his behalf.

Like many psychologists of his generation, Witmer went abroad to study and eventually obtained his doctorate under the direction of Wilhelm Wundt at the University of Leipzig. Wundt trained more American doctorate students in psychology than any other individual in the 19th century. When Witmer returned to the United States after his graduate training, he took a position as a faculty member in psychology at the University of Pennsylvania.

In 1896, Witmer founded the first psychology clinic at the University of Pennsylvania. Margaret McGuire, a student in one of his classes, was a schoolteacher with a student who had difficulty in learning to spell. She asked her professor if he could possibly help with this problem. Witmer reasoned that if this new scientific psychology was really worthwhile, it ought to be able to help with such problems. The boy was brought to Witmer and studied intensively, using various available psychological laboratory procedures. Many of these procedures, such as the study of reaction time, taken from Wundt’s work, have not continued to be used clinically. In any case, on this basis, remedial educational strategies were devised and carried out. These seemed to be helpful. Soon, other individuals were brought to the new clinic, most of them children with problems of academic delay or deviant behavior. As the clinic grew, its staff came to involve PhD students in psychology and a social worker. Also, various physicians were asked to consult on the cases, including a neurologist and an ear, nose, and throat specialist. Witmer presented his ideas for the professional application of psychology to his colleagues at the American Psychological Association (APA) in December, 1896 (Witmer, 1897 ). Their reaction seemed to be lukewarm at best.

Witmer’s graduate students in psychology at the University of Pennsylvania were offered professional training in diverse areas well beyond what might now be considered clinical psychology, branching out to include what is now considered school psychology, speech pathology (Twitmyer & Nathanson, 1932 ), vocational assessment and guidance (Brotemarkle, 1931 ), and industrial psychology (Viteles, 1932 ). His journal, the Psychological Clinic , begun in 1907, continued in publication irregularly into the 1930s, for a total of 23 volumes.

It is a historical curiosity that the professional specialty developed by Witmer more closely resembled the modern field of school psychology than what is now thought of as clinical psychology (Fagan, 1996 ). It is the APA Division of School Psychology, rather than the clinical division, that has chosen to give an annual Lightner Witmer Award. Witmer worked primarily with children, rather than adults and was more concerned with their academic and cognitive functioning than with their emotional life. He was not much influenced by the French clinical tradition pioneered by Charcot and Janet, and completely rejected the work of Sigmund Freud. Witmer favored educationally oriented interventions rather than psychotherapy or behavior therapy, and the medical procedure he most advocated was the surgical operation of removing a child’s adenoids as a way of facilitating normal speech development.

Alfred Binet

Alfred Binet (1857–1911) was originally trained as a lawyer, and taught himself psychology on the basis of his own reading. He was influenced by individuals such as Ribot, the founder of French psychology, and the famous neurologist Charcot. Binet spent most of his career as an experimental psychologist, and founded an annual psychology journal, the first of its kind in France. In 1905, in response to a request from the ministry of education, Binet and his physician colleague Theodore Simon developed what became known as the first practical “intelligence test” for children (Binet & Simon, 1905 ). All of its items met the criterion of a demonstrated increase with age in the percent of children passing them, and the test thus enabled the examiner to estimate the child’s “mental age” or level of intellectual maturity.

Binet’s test materials continued to be used in France informally to gauge children’s profiles of cognitive performance in different areas (Schneider, 1992 ). In English-speaking countries, though, the development and interpretation of the test took some different directions. For example, in Britain, its scores were interpreted in terms of Francis Galton’s theory of intelligence as a mostly inherited personal characteristic (Galton, 1892 ). The concept of a ratio of mental age to chronological age, originating with the German psychologist William Stern ( 1912 ), was used to generate an “intelligence quotient” or IQ, although subsequently the ratio IQ was replaced by standard scores based on a comparison of the examinee to others the same age. Even before the development of Binet’s test, Charles Spearman (1904) had noted the tendency of scores on cognitive test items to correlate with each other (“positive manifold”), and he interpreted their scores as a measure of general ability or “g,” which he hypothesized as a single factor underlying test performance. The American psychologist Henry Goddard had Binet’s test translated into English and validated its ability to diagnose what is now called intellectual disability in children (Zenderland, 1998 ). Lewis Terman refined and standardized Binet’s test in a version that became known as the “Stanford Binet” and provided quantitative norms for it based on a sizable sample of American children (Terman, 1916 ). Terman’s subsequent research followed a group of “gifted” children (with exceptionally high Binet scores) throughout their lives and demonstrated that the test significantly predicted their academic and vocational accomplishments (Terman, 1975 ).

Soon, the most common activity for practitioners of the newly emerging profession of clinical psychologists in America came to be the administration of individual Binet tests, mostly to children, in clinics, schools, and hospitals. In 1908, the first formal psychology internship program began at the Vineland School, a New Jersey institution for those with intellectual disabilities (Routh, 2000 ).

Leta Hollingworth

On December 28, 1917, Leta Hollingworth, J. E. Wallace Wallin, and others founded a new professional organization, the American Association of Clinical Psychologists (AACP) (Routh, 1994 ). It was the first clinical psychology organization, and a direct ancestor of the present-day Society of Clinical Psychology (Division 12 of the APA). On a global level, clinical psychology shares representation as a division of the International Association of Applied Psychology, founded in 1920. Although Wallin was the president of the AACP in the United States and Hollingworth only the secretary, her name is better remembered today. Hollingworth (1886–1939) suggested in 1918 the possibility of a distinct professional degree for practitioners, which she labeled the PsD, or Doctor of Psychology. This suggestion foreshadowed the PsyD degree, now perhaps the most common type of training for clinical psychologists in the United States, and the DClinPsy degree for clinical psychologists in the United Kingdom, now offered by Oxford University, among other academic institutions. Hollingworth also argued for the legitimacy of clinical psychologists as expert witnesses in court.

The AACP only lasted for 2 years as an organization. In 1919, it was assimilated by the APA as its “Clinical Section,” and met annually as part of the APA conventions. For a time, the APA tried to set up a procedure for certifying “consulting psychologists,” but this did not work out very well and was soon discontinued. The APA Clinical Section dissolved itself in 1937, becoming one of the several sections of the new American Association for Applied Psychology. This group continued until 1945, when the AAAP and the APA were consolidated into a new version of the American Psychological Association, which kept the name of the old APA but adopted the structure of the AAAP. The Clinical Section of the AAAP thus became Division 12 of the APA, where it remains today, as the Society of Clinical Psychology. Other national organizations of clinical psychologists, such as that in Britain, mostly did not emerge until after World War II.

Leta Hollingworth is also remembered today as a pioneer advocate of women’s rights. In her day, in the early 1900s, most of the clinical psychologists were men, but now most of them are women. A diary kept by Leta’s mother reported her father’s reaction to her birth in 1886: “I’d give a thousand dollars it if was a boy” (quoted in Klein, 2002 , p. 17). Despite this unpromising reception, Leta Stetter was so precocious that she taught herself to read before she entered school. She became a freshman at the University of Nebraska at age 16, and graduated Phi Beta Kappa 4 years later, an occasion for which she was asked to write the class poem. She became a high school teacher and assistant principal. After her marriage to Harry Hollingworth, she moved to New York City, where he entered a PhD program in psychology at Columbia University. Her application for a job as a high school teacher was turned down because the New York City Board of Education had a rule against hiring married women as teachers. She began to take some graduate classes at Columbia, but was turned down for a fellowship because she was a woman. It is thus quite understandable that Leta Hollingworth then became active in the New York Suffrage Party, seeking the vote for women. Harry Hollingworth received his PhD in psychology in 1909, and began teaching at Barnard College, the women’s branch of Columbia University. He was hired in 1911 by the Coca Cola Company to carry out research using double-blind procedures on the behavioral effects of caffeine. He hired Leta as assistant director of this project, thus initiating her scientific career in psychology. The funds from the Coca Cola project ultimately allowed Leta to enroll as a graduate student in psychology at Teachers College, Columbia University, where she later studied under Edward L. Thorndike. After receiving her master’s degree, she took a part-time job administering Binet tests, an experience that introduced her to clinical psychology. Leta’s research in this PhD program showed no relationship between women’s menstrual status and their performance on tasks in the psychology laboratory. It also failed to support the hypothesis, then a popular one, that women’s intellectual performance is more variable than that of men. After receiving her PhD, she moved on to a career as a professor at Teachers College, Columbia University, where she became a pioneer in the education of gifted schoolchildren (Klein, 2002 ).

The original rationale for the AACP organization centered on the role of clinical psychologists in administering and interpreting intelligence tests. Once Binet’s test was translated into English, it came into wide use in the United States. Wallace Wallin and others argued that this test should only be used by persons who had both academic training in psychology and relevant supervised experience, not by schoolteachers untrained in psychology or by experimental psychologists with no practicum training. The hope was that the new organization would be able to certify and regulate these and other types of “consulting psychologists.” The APA attempted for a time to set up such a professional certification procedure, but this did not work. It was not until 1977 that all U.S. states provided statutory licensing for psychologists.

Despite Lightner Witmer’s initial emphasis on the importance of intervention and remediation, clinical psychologists during the era before World War II were primarily involved in assessment activities, using not only the Binet and other such intelligence tests, but also in the broader domain of personality. Lewis M. Terman, one of the original members of the AACP and a certified “consulting psychologist,” did research further developing the Binet test. He refined and expanded the pool of Binet items, had them administered in a more standardized way, and collected systematic normative data on the performance of children of different ages, producing the “Stanford Binet” test in 1916, which came into common use internationally. Terman initiated important longitudinal research concerning the stability of such test scores and their value in predicting educational, vocational, and other outcomes throughout the lifespan (Terman, 1916 , 1975).

Sigmund Freud

Sigmund Freud (1856–1939) did not originally intend to invent the new discipline he would labeled as “psychoanalysis,” but arrived at it by a circuitous route. After a preliminary education including exposure to the Greek and Latin classics, he entered medical school. His goal was an academic career in the field presently called neuroscience. His prospects for ultimate employment in a university were thwarted, however, in part by Viennese prejudices against Jews. He went into medical practice instead, as a neurologist, so that he could afford to get married (Gay, 1988 ). To prepare for going into practice, he was awarded a fellowship to go to Paris to study under the most famous neurologist of the time, Jean Charcot. Thus, Freud began to use some of the techniques of hypnotism in treating patients with “hysterical” symptoms, but experience with an early patient led him to discontinue the use of hypnosis. Instead, he had patients “free associate,” saying whatever came to mind, and he used the material produced in this way to try to reconstruct the origins of the presenting symptoms. He theorized that such an analysis could alleviate the patient’s problems by detecting unconscious material and bringing it to conscious awareness, allowing the patient to cope with it rationally, hence the saying, “where id was, there shall ego be.” An important aspect of treatment was the phenomenon of “transference,” in which patients became unduly dependent upon their therapists; this was also the subject of the analyst’s comments. In 1900, Freud published his famous book on the analysis of dreams as the “royal road to the unconscious” in psychoanalysis, marking the formal announcement of this new discipline.

Freud came to the United States only once, in 1909, at the invitation of psychologist G. Stanley Hall, to speak at the celebration of the 20th anniversary of the founding of Clark University in Worcester, Massachusetts. Although Freud did not particularly like the United States, it proved to be the country in which psychoanalysis achieved its greatest early recognition. The American Psychoanalytic Association was founded in 1911. As the Boston physician Morton Prince said afterward:

Freudian psychology had flooded the field like a full rising tide and the rest of us were left submerged like clams in the sands at low water. (quoted by Hale, 1971 , p. 434)

The standard method of educating new psychoanalysts, as it developed during the 1920s, came to consist of three parts: didactic instruction in basic principles, a personal psychoanalysis, and experience carrying out the psychoanalysis of patients under supervision. In Europe, the candidates accepted for such training were not necessarily physicians. In fact, no particular professional prerequisites were enforced, and thus a number of psychologists received psychoanalytic training. The European psychologist Theodore Reik, who worked as a psychoanalyst after emerging from such training, was taken to court on charges of practicing medicine without a license. Freud, on the witness stand, testified that psychoanalysis was actually a part of psychology rather than of medicine, and thus Reik’s use of psychoanalysis with his patients was legitimate. Reik won his case (Freud, 1927 ). Nevertheless, in 1938, the American Psychoanalytic Association began to enforce the rule that only physicians might be trained for the practice of psychoanalysis. Because Freud was struggling to leave Vienna in 1938 to escape the Nazis and died in London in 1939, he was hardly in any position to intervene personally in this American dispute. The controversial rule was not overturned until 50 years later, in 1988, when the case of Welch v. American Psychoanalytic Association ( 1985 ) was settled out of court. Now, psychologists may be accepted as candidates for psychoanalytic training in the United States, just as they always had been in other countries. By then, however, the use of psychoanalysis began to wane in the United States.

Before World War II, very few American psychologists worked as psychotherapists, psychoanalytic or otherwise. The same was true of U.S. psychiatrists, whose activities centered on the administration of mental hospitals and the care of psychotic or demented individuals. The war changed all that. For one thing, large numbers of European immigrants, including many psychoanalysts, arrived in the United States, fleeing Hitler. These European analysts formed a cadre for training others in this country. American psychiatrists were able to receive such training through the American Psychoanalytic Association, and psychologists wanting this kind of training were often able to obtain it in irregular ways, including via Theodor Reik’s National Psychological Association for Psychoanalysis, in New York.

In addition, the U.S. Armed Forces required many clinicians to deal with the mental health problems that often accompany a war, including what is now labeled post-traumatic stress disorder. Not enough psychiatrists were available to carry out these duties, and thus many doctoral psychologists were brought into mental health–related work. The chief psychiatrist of the U.S. Army during World War II was Brigadier General William C. Menninger, a man strongly identified with psychoanalysis. After the war, the mental health problems of military veterans loomed large. The U.S. Veterans Administration began a massive program of financial support of training in all mental health fields, including psychiatry, psychology, social work, and nursing. The Department of Veterans’ Affairs, as it is now known, is still the largest single employer of clinical psychologists in this country. At the same time, a new federal agency, the National Institute of Mental Health (NIMH) was organized as part of the National Institutes of Health, with responsibilities for supporting both research and training in mental health fields. In response to these federal initiatives, a conference on graduate training in clinical psychology was held in Boulder, Colorado, in 1949. The Boulder Conference (as described by Raimy, 1950) yielded the “scientist-practitioner” model for training clinical psychologists. The recommended curriculum closely followed the model elaborated by psychologist David Shakow, the first chief clinical psychologist at NIMH. Shakow’s career was exemplary in its blend of scientific experimental psychology and a psychoanalytic orientation to clinical work. The Boulder Conference formed the basis of a system of graduate programs and internships operating under a new program of accreditation offered by the APA. Many of these new PhD programs in clinical psychology, for example the one at the University of Michigan, incorporated the psychoanalytic training model relatively fully, including didactic instruction, encouragement of personal psychoanalysis, and the supervision of psychotherapy by qualified psychoanalysts.

Meanwhile, clinical psychology was emerging as a discipline in several other countries. After World War II, the United Kingdom, the Scandinavian countries, and others were setting up government-supported national health services (rather than government-supported care for veterans alone). In each of these national health services, clinical psychologists became a mainstay of mental health care, and the psychoanalytic model was as influential in these places as it was in the United States at this time.

Psychoanalysis seems to have reached the peak of its influence in the United States in the mid-1960s. By that time, a large number of the departments of psychiatry in U.S. medical schools had hired psychoanalysts as chairs. After that, Freudian influences in mental health care appeared to wane. One factor in this decline was the reluctance of the psychoanalytic community to subject its treatments to rigorous research concerning their efficacy and effectiveness. A second factor was the cost of treatment, especially of the classical Freudian paradigm, in which patients were seen 5 days a week, sometimes for years on end. Third, by the 1950s, a number of lower-cost, more demonstrably effective pharmacological treatments were emerging for mental health problems, including neuroleptics for managing psychotic behavior, antidepressants, mood stabilizers, anxiolytics, and others. Finally, alternative psychological treatments began to emerge, including the cognitive and behavioral therapies discussed under the next heading.

Hans Eysenck

Hans Eysenck (1916–1997) was important to clinical psychology as one of the founders of behavior therapy. The cognitive and behavioral therapies emerged during the latter half of the 20th century as credible alternatives to psychoanalysis. Eysenck was a German who was a firm opponent of the Nazis and soon emigrated to Great Britain. He received his PhD from the University of London, in psychometrics and experimental psychology, under Cyril Burt and was recruited by the prominent psychiatrist Aubrey Lewis to the Institute of Psychiatry at the Maudsley Hospital in London, to start a program in clinical psychology. Eysenck assumed at first that clinical psychologists should occupy themselves only with research and assessment activities, rather than treatment. He was a researcher, himself. In his work, he preferred to collect and analyze data and write articles and books, rather than deal directly with patients as a clinician. In 1949, Eysenck journeyed to the United States (to the University of Pennsylvania), where he began to realize and to agree with the commitment of the post-war generation of clinical psychologists to treatment, and not just assessment (Eysenck, 1949 ). However, he had no use for the psychoanalytic approaches in which so many of them were interested. He soon scandalized both psychiatrists and psychologists by publishing an article questioning the positive effects of psychotherapy (Eysenck, 1952 ). In his article, Eysenck described insurance company data that permitted a comparison between the outcomes of persons with neurotic problems who received psychotherapy and others who did not. He pointed out that the success rate of psychotherapy did not exceed the rate of “spontaneous remission” of the patients’ difficulties without therapy. Although not a controlled study including random assignment of patients, it did point out the flaw in therapists’ previous reasoning that if patients improved after treatment, the treatment must have been responsible.

Eysenck thought that psychological interventions should be based not on Freudian notions, but on ideas compatible with the theories and quantitative, experimental findings of the type of behavioral psychology that was typical of the academic psychology of his day. In his new Department of Psychology at the Institute of Psychiatry, he hired behaviorally oriented colleagues such as Gwynne Jones and began to train students like Stanley Rachman. Psychiatrist Aubrey Lewis objected to the direction being taken by Eysenck’s program, but academic officials at the University of London supported the autonomy of the Psychology Department at the Institute of Psychiatry.

The Modern Era

What do these developments imply for the status of psychoanalysis? It is clear that Sigmund Freud was a powerful and persuasive writer, and that the cultural influence of his works to this day may be broader than that of any other individual in psychology. Freud’s continuing influence within clinical psychology is also considerable. Yet Freud depended largely on the evidence of case histories, never did a psychological experiment, did not make use of quantitative methods, and generally ignored the research literature of nonpsychoanalytic psychology. Many of Freud’s medical and psychological colleagues were critical of his approach from the beginning, a fact that is curiously portrayed in histories of psychoanalysis as an example of unconsciously motivated “resistance.” Eysenck and his behavioral colleagues simply had the boldness to call the Freudians to account and to engage in much-needed critical thinking about the relevant evidence.

Meanwhile, support for the behavior therapy movement quickly appeared. A behavior modification conference was held in Charlottesville, Virginia, in 1962, and the first behavior therapy journal, Behaviour Research and Therapy , began publication in 1963. The interdisciplinary Association for the Advancement of Behavior Therapy first met in 1967, in Washington, D.C., and its name was changed in 2005 to the Association for Behavioral and Cognitive Therapies. Behavioral principles had a profound influence on research and the practice of therapy. In terms of research, pioneering work was carried out by physician Joseph Wolpe of South Africa, described in his 1958 book, Psychotherapy by Reciprocal Inhibition . A pioneer in the area of cognitive therapy was psychiatrist Aaron T. Beck (e.g., Beck, 1967 ). The Skinnerian version of intervention for behavioral problems is known as applied behavior analysis and has been particularly valuable in working with persons with intellectual and developmental disabilities, including those with autism (Baer, Wolf, & Risley, 1968 ).

By the 1980s, the larger scientific community finally began to realize the need for formal randomized clinical trials to evaluate the effectiveness of treatments for psychopathology. Elkin et al. ( 1989 ) reported the results of the NIMH Treatment of Depression Collaborative Research Program. Participants in this research were outpatients between the ages of 21 and 60 who met the current Research Diagnostic Criteria for major depressive disorder with specified scores on the Hamilton Depression Rating Scale. Those with other major psychiatric disorders, concurrent psychiatric treatment, or certain medical conditions were excluded, as were actively suicidal individuals. Of 250 potential subjects, 239 entered treatment, of whom 162 completed treatment. They were randomly assigned to either interpersonal psychotherapy, cognitive behavior therapy, imipramine plus clinical management, or pill placebo plus clinical management (medication was administered on a double-blind basis). The psychological treatments were carried out by 13 different therapists, in accordance with detailed treatment manuals. The results showed that the antidepressant medication and the two types of psychological treatment were all significantly more effective than pill placebo but were essentially equivalent to each other in their effects on depression. Critics of such research were quick to point out the additional need for studies on the “effectiveness,” not just the “efficacy” of such treatments. In other words, the clinical trials with their formal manuals of procedure were not representative of typical clinical management, and the exclusion conditions made the patients studied also unrepresentative of the broad population of depressed patients. Nevertheless, it is clear that with the NIMH Collaborative Research and similar studies, a new era had arrived. The subsequent emphasis has been on the need for all therapists, when possible, to use “evidence-based” treatments of psychopathology, rather than procedures that have not been tested in a rigorous way. Similarly, the training of all mental health personnel should give priority to teaching treatments that are firmly grounded in the research literature. This is not to deny, however, that clinicians are constantly experiencing variations in the pictures presented by patients’ problems, thus requiring a flexible adaptation of established principles.

This chapter has dealt with a number of strands in the development of Clinical Psychology with a “large C,” including its psychoanalytic and cognitive-behavioral aspects. Many psychologists who deliver human services in the United States are specialists in other fields, and are thus are identifiable as clinicians “with a small c,” so to speak. Among these areas are clinical child and adolescent psychology, clinical health psychology, clinical neuropsychology, counseling psychology, rehabilitation psychology, couple and family psychology, clinical geropsychology, school psychology, and in some jurisdictions, clinical psychopharmacology. Early on, in some cases, clinical psychology and school psychology were the same field, but later branched into distinct ones. The history of how each of these special areas developed would require many additional chapters. In many countries in Europe, Latin America, and in many other parts of the world, the patterns of training seen in psychology in the U.S. and the U.K. is not typical. Instead, university psychology graduates receive a diploma or licentiate degree, which is in itself legally sufficient for them to engage in the practice of psychology, although many supplement this by informal training in areas such as psychotherapy. In such countries, master’s and doctoral degrees are considered to be preparation for an academic career, not for practice.

My largest effort toward studying the history of clinical psychology is the 1994 book on the history of the organization presently known as the Society of Clinical Psychology, a division of the APA. It was subtitled: “Science, Practice, and Organization,” so perhaps these categories will serve in discussing the history of clinical psychology as a larger entity. Clinical psychologists seem to be well accepted as contributors to the scientific study of psychopathology, assessment, and treatment. Their progress in this respect can perhaps be tracked through the volumes of the Annual Review of Clinical Psychology , which began publication in 2005.

In terms of practice, doctoral-level clinical psychologists are prominent in the public sector, practicing in Veterans Affairs Hospitals and clinics in the United States and, the in national health services of Great Britain, the nations of the British Commonwealth, and Western Europe. Employment in private-sector mental health is highly competitive in such countries. Psychiatry, once the leading profession in this domain, has lost much of its turf to primary care physicians (and advanced practice nurses), who now write most of the prescriptions for psychotropic medications. Moreover, psychiatry has also lost professional turf to various kinds of nonmedical psychotherapists, including not only doctoral-level psychologists but also master’s-level psychologists, social workers, mental health counselors, and many others. Current research does not support the idea that therapists with such different types and levels of professional preparation differ in their effectiveness in treating mental illness. And yet, despite all this professional activity, the mental health needs of the public still do not appear to be very well served. A study by Pratt and Brody ( 2008 ) of “depression in the United States household population, 2005–2006,” might be taken as a snapshot of the status quo a few years before the beginning of the current world economic recession. A sample of about 5,000 persons representing the adult, civilian, noninstitutionalized U.S. population were given standardized interviews (National Health and Nutrition Examination Survey). Only 29% of those people considered to suffer from depression reported contacting a mental health professional (such as a psychologist, psychiatrist, psychiatric nurse, or clinical social worker) in the past year; of those with severe depression, only 39% reported such contact. Depression is considered a highly treatable condition, yet most people with depression in the United States were not treated. It is clear from such data that clinical psychologists and other mental health professionals have a long way to go to meet their goal of actually helping people even to a minimal extent.

Finally, in terms of organization, clinical psychologists in the United States have been represented by some kind of professional organization since 1917. Similar organizations began to appear in Great Britain, British Commonwealth countries, and in Western Europe, especially after the end of World War II. However, so far, international clinical psychology has not yet gone very far toward dealing with the kaleidoscope of world cultures in existence or achieving any kind of a coherent, organized voice. These remain as issues for the future.

Acknowledgments

I very much appreciate comments by colleagues on a preliminary version of this manuscript. These helpful early readers included David Barlow, John Cox, Nicola Foote, Christopher Green, Marjorie Sanfilippo Hardy, and Irvin D. S. Winsboro.

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Prospect Theory: A Bibliometric and Systematic Review in the Categories of Psychology in Web of Science

Júlia gisbert-pérez.

1 Departamento de Psicología Básica, Universitat de València, Avgda. Blasco Ibañez 21, 46010 Valencia, Spain

Manuel Martí-Vilar

Francisco gonzález-sala.

2 Departamento de Psicología Evolutiva y de la Educación, Universitat de València, Avgda. Blasco Ibañez 21, 46010 Valencia, Spain

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Prospect Theory (PT) is an alternative, dynamic explanation of the phenomenon of risky decision making. This research presents an overview of PT’s history in health fields, including advancements, limitations, and bibliometric data. A systematic and bibliometric review of the scientific literature included in the psychological categories of Web of Science (WoS) was performed following the PRISMA 2020 statement for systematic reviews. A total of 37 studies (10 non-empirical and 27 empirical) were included in the sample. Bibliometric results showed thematic variability and heterogeneity regarding the production, researchers, and methodologies that are used to study PT. The systematic results highlight three main fields of PT research: preventive and screening behaviors, promotion of healthy habits, and COVID-related decision making. Personal and contextual factors which alter the usual pattern specified by PT are also described. To conclude, PT currently has an interdisciplinary character suitable for health promotion, with recent studies broadening its applicability.

1. Introduction

Decision making under risk has been a subject of social research for several centuries. This extensive scientific interest has allowed the development of a large theoretical and experimental body on decision making under risky conditions [ 1 ], leading to new models that have attempted to solve problems such as the excessive emphasis on normativity. This paper highlights the contribution of Prospect Theory (PT).

PT was created by Kahneman and Tversky [ 2 , 3 ]. It developed as an alternative explanation of risky decision-making processes to Expected Utility Theory [ 4 ]. PT contemplates the presence of heuristics and limitations in human cognition, which result in biases and deviations from what is considered normative. However, these deviations are considered systematic and could be studied to improve decision making [ 5 ].

PT is based on two fundamentals. The first points out that, in deciding between the different choice options, we depend on a frame of reference and not so much on the absolute value of the options, which violates the economic conception of rationality. The second foundation of the theory is loss aversion bias. Loss aversion refers to a greater sensitivity to potential losses than to potential gains of equal magnitude [ 5 ].

To justify these assumptions, controlled experiments were developed in which participants had to choose between different alternatives (usually two) with different probabilities of achieving certain outcomes [ 2 , 6 ]. The obtained results showed that the decision process comprised two phases, the editing phase and the evaluation phase. First, a reference point was set and the possible outcomes were framed as benefits or losses. The process ends with a personal assessment of the usefulness of the options [ 2 , 7 ]. Among the basic findings and principles of Kahneman and Tversky’s theory [ 2 , 3 ], the S-shaped value function, the four-fold pattern of risk preferences, the “probability weighting function”, the uncertainty effect, and “the reflection effect” are worth mentioning.

PT is a descriptive theory of human behavior which does not explain how people should theoretically make their decisions, but how they actually do [ 8 ]. It has been applied, not without difficulties, to different contexts, such as economics [ 5 , 9 ] and politics [ 10 , 11 , 12 ]. Likewise, its assumptions have been analyzed in more specific conditions, such as energy efficiency investment [ 13 ], terrorism [ 14 ], political participation [ 15 ], or climate policies [ 16 ].

One of Kahneman and Tversky’s key insights was that the way risky decisions are framed influences what is selected, and it does so in a way captured by the assumption of an S-shaped value function defined on changes from the status quo [ 2 , 17 ]. Health decisions inherently involve risky choices [ 18 ]. Thus, consistent with what PT predicts, subsequent work demonstrated that the way in which health information is framed (to focus on potential gains (e.g., benefits of healthy behavior) versus losses (e.g., harms of unhealthy behavior)) systematically influences decisions and choices [ 17 , 19 ]. In addition, the COVID pandemic also involved risky decision making at the societal level. Consistent also with PT, gain- or loss-framing of health information influenced decision making, and risk-free behaviors may be promoted [ 20 ].

In addition to the framing effect, alterations in the expected pattern of loss aversion have also been studied. Regarding PT in the psychological field, its application in substance addictions stands out for its inherent risky decision making. [ 21 ]. According to PT, low levels of loss aversion increase the likelihood of engaging in addictive behaviors. Drug users have been found to show lower loss aversion than non-users [ 21 ]. All of this can be taken into account by healthcare personnel to understand the resistance and ambivalence in the decision-making processes in consumer patients.

Given its long-standing interest and applicability, the aim of this study is to conduct a bibliometric and systematic review of the PT literature in health settings within the psychology categories of Web of Science (WoS), in order to provide an overview of the usefulness, applicability and limitations of the theory within this scientific discipline. This will allow the creation of a new resource pool from which replications of previous studies, scientifically argued critiques, or even new experiments or theories can emerge, leading to more critical and informed scientific developments. It may also help psychology and health professionals to understand human cognitive issues and promote good health.

2. Materials and Methods

A systematic and bibliometric review of the scientific literature of Prospect Theory [ 2 , 3 ] in the main WoS database was conducted. A protocol was registered in PROSPERO, with identification code CRD42022348325. The search was conducted in September 2022 following PRISMA 2020 statement for systematic reviews [ 22 ]. SPSS 22 statistical package, R package Bibliometrix [ 23 ] and WoS analysis were used for the bibliometric review.

2.1. Information Sources and Search Strategy

A search was performed in the Web of Science database (Core Collection) with the search term “prospect theory” and “health”. Other databases were not consulted due to the number of studies identified and the objective of exploring the WoS psychology categories.

2.2. Eligibility Criteria and Selection Process

In the systematic search, the inclusion criteria were (a) containing the term “prospect theory” and “health” in topic, (b) being a scientific article, (c) being included in one of the psychological WoS categories: “behavioral sciences”, “neurosciences”, “psychology”, “psychology applied”, “psychology biological”, “psychology clinical”, “psychology educational”, “psychology experimental”, “psychology mathematical”, “psychology multidisciplinary”, “developmental psychology”, “psychology psychoanalysis”, or “psychology social”, and (d) being written in English or Spanish.

The exclusion criteria consisted o” (a)’addressing other topics (n = 80), (b) articles on other theories (n = 20), and (c) articles that were book chapters (n = 7). The selection and screening process is shown in Figure 1 .

Flowchart of the selection and screening process of the systematic review articles according to the PRISMA method.

The selection process was performed by two investigators independently and then combined to reach a consensus. A third investigator supervised the results to confirm the quality of their work.

2.3. Data Extraction

After the selection and analysis process, the final sample contained 37 articles.

For the bibliometric review, the following variables were considered: year of publication, number of authors, distribution by country and continent, university affiliations, areas of research in psychology according to WoS, scientific journals, and key concepts. To perform the keyword co-occurrence networks), not all the terms were included, eliminating isolated nodes. For the systematic review, the following variables were considered: authors, year of publication, type of study, and main objective. For the empirical studies, we also extracted information on the sample, the methodology, the existence of a control group, and the main results and limitations. The bibliometric data extraction process was carried out using the WoS indicators, while data extraction for the systematic review was performed in the same way as the study selection process.

3.1. Results of Bibliometric Review

Regarding TP production in the health field, the Figure 2 presents an irregular and increasing distribution with the highest production peak in 2021. In this year, several of the publications focused on the study and promotion of health behaviors in the COVID pandemic. The interest in applying PT to the field of health seems to have started in 1997, 18 years after the original study [ 2 ], indicating that the initial interests of this theory were focused on other fields. The last decade (2012–2022) accumulates 57% of the publications, highlighting the growing interest.

Annual scientific production.

The sample includes 112 authors. Mainly, the contribution of P. Salovey (Yale University) to the field of health in PT (4 publications) stands out, followed by G. J. De Bruijn (University of Amsterdam) and A. J. Rothman (University of Minnesota System) (3 publications). The rest of the authors contribute in 2 (12% of authors) or 1 publication (86%).

Figure 3 shows the distribution of scientific production by country, considering both internal (CMI) and international (CCM) collaborations. The sample included 12 countries in the Americas, Europe, Asia, and Oceania, and a total of 142 related publications. The USA had 81 linked publications (57%), followed by the Netherlands (16; 11%) and Canada, China, and Germany (7; 5%). Accordingly, the top five universities with the highest affiliations are Yale University (4), Maastricht University (3), University of Amsterdam (3), University of Minnesota System (3), and University of Minnesota Twin Cities (3).

Country scientific production.

With 5 or fewer linked publications are Singapore, the UK, Australia, and France (4), Italy (3), South Korea (2), and Spain (1). Regarding international collaborations, the USA stands out with Canada and the Netherlands with two collaborations, followed by Germany–Spain–Netherlands, USA–Italy, and USA–South Korea with one collaboration.

Regarding the WoS psychology categories, the areas that appeared to be most linked to PT and health are Multidisciplinary Psychology (13 publications), Clinical Psychology (10), Psychology and Social Psychology (8), Applied Psychology (3), Experimental Psychology and Behavioral Sciences (2), and Developmental Psychology and Neurosciences (1). Among the categories that did not belong to Psychology, Economics and Public Environmental Occupational Health (2) and Gerontology, Hospitality Leisure Sport Tourism, Management, Nutrition Dietetics, Oncology, Psychiatry, Social Sciences, and Biomedical and Sport Sciences (1) stood out ( Table A1 ).

A total of 27 scientific journals present articles related to PT and health. The scientific journals with the highest number of articles on PT in the area of health are the British Journal of Health Psychology , Health Psychology , and Journal of Applied Social Psychology (3, respectively). Journal of Behavioral Medicine, Journal of Economic Psychology, Psychology Health and Social , and Personality Psychology Compass have two publications each. The remaining 20 have only one publication.

By analyzing the keyword co-occurrence networks, a general picture of the predominant terms in the study of PT and health was obtained. Figure 4 shows that “prospect-theory” was the term with the highest intermediation, i.e., presenting the highest number of links to other keywords. The other terms with the least intermediation were “intentions”, “loss-framed messages”, “behavior”, “perceptions”, “information”, and “attitudes.” The size of each block indicates the frequency of occurrence as an intermediate word. The figure shows three groups of keywords (blue, red, and green) and a closer link (by the thickness of the link) between “prospect-theory-behavior” and “behavior-intentions”.

Co-occurrence network.

3.2. Results of Systematic Review

Table A1 and Table A2 in Appendix A (non-empirical studies and empirical studies, respectively) show a synthesis of the data from the studies in the sample. Ten non-empirical studies (published between 1997 and 2021) and twenty-seven empirical studies (published between 1999 and 2022) were found.

3.2.1. Prospective Theory and Health Care Field

According to DeStasio [ 18 ], there are three main contributions of PT to the health domain. First, PT indicates that people will act differently depending on whether a situation is gain- or loss-framed compared to some reference point. Second, the reference point may have a particular impact on preventive health behaviors that are unpleasant themselves (e.g., vaccinations or invasive screening tests), where the risk of the immediate negative outcome (e.g., pain) is felt higher than the risk of the potential long-term outcome. Third, PT predicts that reframing health outcomes with respect to certainty would change decisions about health behaviors (as there is often an overweighting certainty).

PT assumes that people respond predictably to potential gains and losses. They are risk-seeking when confronted with information about losses, but risk-averse when confronted with information about gains [ 19 ]. Thus, in the health field, gain-frames may be more beneficial to promote preventive behaviors, as well as loss-frames to favor detection behaviors [ 24 ]. One possible explanation is that prevention behaviors are perceived as low risk, while detection behaviors are perceived as high risk [ 19 , 25 , 26 ].

There have been many examples of successful use of PT in modeling decision making in health care settings. For example, it has been used to model health behaviors such as disease treatment [ 26 ], disease prevention [ 27 , 28 , 29 , 30 , 31 ], and encouraging altruistic behaviors such as egg donation [ 32 ]. On the one hand, Fridman et al. [ 26 ] investigated the relationship between physicians’ gain-loss recommendations and prostate cancer patients’ treatment choices. Results showed that physicians’ use of loss-related words correlated with recommendations for cancer treatment, and loss words were associated with patients’ choice of treatment. On the other hand, similar results to those hypothesized by PT were obtained in disease prevention studies, but variables have been found to influence the framing effect such as cultural differences [ 28 ] and credibility of the result [ 30 ]. However, having family members with the disease to prevent did not influence decision making [ 31 ].

Another focus of PT study has been life attitudes in healthy and sick patients and reference point [ 33 , 34 , 35 , 36 , 37 ]. Current health status determines one’s reference point. The reference point for an advanced cancer patient with a short life expectancy will be closer to death compared to an older adult with many years of expected survival. Thus, ill patients would prefer prolonging their life over quality of life, as was found in the results [ 33 , 34 , 36 ]. Likewise, sick patients rated a mild and a severe disease situation very differently, but healthy patients rated the two scenarios as much more similar [ 35 ]. In addition, having an overly pessimistic view of old age (e.g., not correctly predicting one’s own ability to adapt to the health problems of old age) may produce a self-fulfilling prophecy, showing reduced sensitivity to loss and impacting their health behaviors (e.g., underinvesting in future health) [ 37 ].

Given PT usefulness, public health (PH) agencies could perhaps benefit from utilizing PT in a way that would optimize the effectiveness of PH messaging to increase overall local and global adherence [ 24 ]. On the one hand, expectations and disappointment regarding health may influence happiness. A practical implication would be that doctors exaggerate the risk of bad health outcomes in the future, and emphasize that patients could not have prevented bad current outcomes [ 38 ]. On the other hand, the differences in reference point in healthy and sick people can be applied to the promotion of care or insurance plans, considering the preferences of both groups [ 33 ]. Lastly, depending on the intention to prevent or treat, gain-loss frameworks can be applied to achieve attitudinal and behavioral changes [ 24 ].

Despite all the potentialities of PT, it also has weaknesses. For instance, Van’t Riet’s review [ 39 ] includes studies of framing in the health care setting with contradictory results [ 39 , 40 ]. Therefore, it is necessary to carry out precise analyses of the subtle differences in the messages that may influence the receptors’ reactions.

It should be noted that in decision making, it is important to consider variables beyond framing and risk. Among the studies reviewed, personality aspects such as psychopathy, ambivalence (e.g., persistence of attitudes, resistance to change), impulsivity, anxiety, or health involvement stand out [ 41 , 42 , 43 ]. Overall, personality characteristics of the respondents played a more important role as predictors of risk choices mainly in the negative frame [ 42 , 43 ]. Likewise, with individuals with high ambivalence, a greater persuasion appears with a negative framing (and vice versa), due to a possible negativity bias [ 41 ].

3.2.2. Prospect Theory on Promoting Healthy Habits

PT has also been used to promote health-related attitudes and behaviors, which may reduce the occurrence of diseases. In the study of the framing effects on health issues, gain frames generally had an advantage over loss frames in promoting preventive behaviors (e.g., physical activity) [ 44 , 45 ]. Gallagher and Updegraff [ 44 ] concluded that “how a health message is framed is an important consideration in designing messages that promote preventive behaviors’’. In this regard, a gain message was associated with better semantic and affective evaluations of the message, but also a prime/frame and frame/source valence match was found more persuasive [ 45 ]. Hence, semantic consistencies must be taken into account, as they moderate the influence of message framing.

Therefore, it makes sense that, in the case of health-affirming behaviors such as physical activity (PA), messages framed around gains (i.e., benefits) rather than losses (i.e., costs) are often more effective [ 19 , 45 , 46 ]. PT has been applied through framed messages to promote PA [ 47 ], as well as the use of fitness apps [ 48 ]. The results of these studies showed an advantage of gain-framed messages in promoting sport intentions and attitudes, self-efficacy and sport practice itself [ 46 , 48 ]. Likewise, the effects of the framed PA messages were studied across all age and sex groups, demonstrating that older men may especially benefit from PA messages due to a possible age-related positivity effect [ 47 ].

In this context, although the gain frame in PA promotion is often more effective, it is important to consider the motivations associated with PA behavior and how the frame fits with these motivations [ 44 ]. All of this implies that the effect of framed messages is not simply based on the function of detection or prevention, but that personal motivations and interpretations must be considered. In addition, a possible interaction between source credibility and frame should be considered, as the gain frame together with a credible source (e.g., a physician) indicated higher exercise intentions and behaviors [ 49 ].

PT has also been applied to the promotion of healthy eating. On the one hand, PT predicted that the perceived positive value (i.e., benefit) associated with accumulating gains grows in an asymptotic, rather than linear, function [ 2 ]. This function applied to healthy intake suggests that less health gain may be associated with eating more pieces of fruit, and consequently, after having eaten a piece of fruit, individuals may see less value in eating more. This hypothesis was somewhat supported; health benefits that people assign to consuming increasing amounts of fruit appear to increase, but only if consumption of a variety of fruits throughout the day is considered [ 50 ]. On the other hand, the effect of autonomy on framing effects and fruit and vegetable consumption has been studied. Churchill and Pavey [ 51 ] observed that gain-framed messages only boosted fruit and vegetable consumption among those with high levels of autonomy; therefore, autonomy moderated the framing effect.

This gain-framing effect on preventive behaviors was also present in the use of sunscreen. Individuals who read gain-framed messages compared to the loss-framed ones were more likely to ask, repeatedly apply, and use sunscreen at the beach [ 52 ]. At the neural level, these results are consistent with greater activation of the medial prefrontal cortex (MPFC) to gain-framed messages. Higher MPFC activation reliably predicts subsequent behavior [ 53 ].

Moreover, in this sense, de Bruijn [ 54 ] explored the message framing effects to promote dental health using mouth rinse for 2 weeks. Their results coincided with the promotion of preventive actions, the gain-framed information to emphasize the preventive use of mouthwash being more appropriate. No framing effects were found in the detection conditions.

Frame effect on tobacco smoking cessation has also been studied [ 55 ]. Through messages framed in gain and loss and images illustrating positive and negative consequences, it was found that the intention to quit smoking was greater when negative images (e.g., unhealthy mouths) appeared, as well as when pictures of healthy mouths illustrated the presence of preventive action. On a practical level (e.g., health campaigns), the use of fear appealing communications with vivid negative images is one way to reduce tobacco use.

3.2.3. PT, COVID Pandemic, and Social Behaviors

Understanding framing effects in PH messaging is important for improving adherence, and it is particularly important when considering messaging where loss of life can be avoided, such as during the COVID-19 pandemic [ 24 ]. PT has been used to study risky decision making and the promotion of behaviors to reduce virus transmission, such as physical distancing or vaccination. People’s behavioral response to a health crisis depends on how they perceive threat and their level of risk tolerance. Through PT, public health messages can be framed to influence adherence to health recommendations, taking into account other factors that may affect adherence.

Doerfler et al. [ 56 ] focused on risky decision making during the pandemic and its relationship with Dark Triad traits. Their results coincided with those presented by Tversky and Kahneman [ 57 ]. In a gain scenario (lives saved), individuals were more likely to opt for the certain option, thereby displaying a bias toward risk-aversion. In a loss scenario (lives lost), individuals were more likely to take greater risks.

During the COVID pandemic, maintaining an adequate physical safety distance was necessary to prevent the spread of the virus, especially indoors. Neumer et al.‘s [ 58 ] online and field experiment with manipulated gain- or loss-framed messages showed that loss-framed messages were more effective than gain-framed ones promoting physical distancing. The loss-frame advantage suggests that uncertainty about the true effectiveness of distancing to avoid contracting COVID-19 is high and that people are more willing to accept this uncertainty when faced with a potential loss than gain.

Another behavior studied since PT has been vaccination during the pandemic. Vaccination is an important tool to end pandemics, but the majority of the public must be willing to be vaccinated to reach herd immunity. Using health message framing, Reinhardt and Rossman [ 43 ] conducted an online experiment with framed messages with younger and older samples. Loss frames lead to significantly more positive vaccination attitudes in younger adults than gain frames, which affects their vaccination intentions. However, the effects of gain- and loss-framed messages on vaccination attitudes and intentions in older adults did not differ significantly. This difference was explained by an age-related positivity effect in the older sample, since they ignored the negatively framed information in the loss frame condition and focused on the positive ones.

Finally, some moderators studied in relation to the framing of health message interventions during pandemics have been respondents’ age, targeted beneficiaries (self or community), uncertainty (as mentioned above), loss-framing reactance, and personality traits as psychopathy, as mentioned above [ 24 , 43 , 56 ]. In relation to health, the age of respondents may imply differences in framing effects for variables such as positivity in older people [ 43 ]. Furthermore, greater persuasion has been found when messages are directed at the respondents themselves as opposed to the general community. Reactance is directly associated with attitudes and behaviors and is expressed in negative cognitions and emotions; therefore, it may result in more negative attitudes towards the promoted behavior [ 56 ]. Lastly, psychopathy emerged as the significant predictor of risk taking during the COVID-19 crisis.

4. Discussion

PT is a theory that attempts to explain dynamic changes in decision making, including aspects ignored by rational choice theories and highlighting the importance of situation and value in decision making [ 59 ]. In this study, a systematic review and bibliometric analysis of the literature on PT and health-related fields included in the WoS psychology categories was performed. The results of the bibliometric analysis have shown a growing international interest in the application of PT in health issues. The USA, followed by the Netherlands and Canada, have contributed the largest amount of literature on PT in health care settings. The analysis of the co-occurrence networks showed that the most frequent terms were prospect theory, intentions, behavior, and loss-framed messages, indicating the main interests of the application of PT in health.

Regarding the results of the systematic review, heterogeneity has been found in the topics, methodology, and even in some results. The application of PT in health has mostly focused on the framing effects to promote health behaviors and the importance of people’s reference point. On the one hand, it has generally proven useful to use a gain frame to promote preventive health behaviors, whereas a loss frame seems to be more useful for treatment or detection behaviors. Therefore, when decision making involves low risk, gain-framed messages may be more effective, as well as loss framed messages in high-risk decisions. On the other hand, current health status is a key factor in decision making, as it determines the personal reference point. Current health status can influence the choice of future treatments or preferences about longevity or quality of life.

Other areas in relation to health that have been studied in PT have been the promotion of healthy habits. PT has been shown to be useful in promoting healthy habits, using gain-framing primarily. These behaviors, in turn, can be preventive, thus promoting wellness. Furthermore, the COVID pandemic situation has allowed numerous applications of PT in an intrinsically risky and uncertain context, especially in the promotion of preventive behaviors (e.g., social distancing, vaccination).

In summary, from a PT perspective, it is possible to encourage certain health-related behaviors depending on the framing, decision risk, and variables that may influence decision making. It is important to note that some results have been shown to be contradictory, thus requiring an analysis of the choices to be balanced, as well as consideration of variables that may influence decision making (e.g., personality traits, certainty of sources, cultural differences, age). All this can be taken into account when developing preventive or screening programs, as well as to promote healthy behaviors, considering the particularities of the targeted social sector (e.g., healthy or sick people).

In conclusion, this systematic and bibliometric review provides interdisciplinary evidence of the functionality of PT for the study of decision making under risk, highlighting both PT basis and factors that modify the expected decision patterns. Although these factors can be considered to hinder the applicability of PT, knowing its limitations can be very beneficial in extending the theory to new fronts. Understanding cognitive aspects such as decision making is essential in fields such as psychology and health, as it allows planning better assessments and interventions to promote well-being.

4.1. Limitations

The present study has several limitations. First, including only articles in the sample limits the complete knowledge of the study topic. Second, due to the size of the sample and the interest in the psychological categories of the WoS, other databases were not consulted. This meant that only studies categorized within the areas of psychology in WoS were included, thus providing a bibliometric and systematic approach limited to this area, which explains why studies such as the original [ 2 ] are not included in the sample. The interest in the psychological fields and PT lies in the importance of the cognitive part in decision making and its importance as a health science. Third, aspects such as the sampling method or the method of information extraction have not been considered because little information was provided in the articles in the sample.

4.2. Future Directions

First, a study of similar characteristics is proposed in other fields to broaden the study of PT. Second, it is proposed to conduct empirical studies that apply PT to specific fields or problems related to cognitive aspects or decision making within psychology and health, such as behavioral addictions. Third, it would be interesting to continue with the study of variables that alter the patterns expected by PT in order to extend the scientific knowledge. In this way, a more complete scientific framework would be obtained and the scope of the theory itself would be broadened. Fourth, it would be very useful to create a training program for health care and health professionals to promote preventive health behaviors and treatment. In this line, it would be interesting to test the applicability of PT with minors, in order to promote healthy habits in early ages.

Non-empirical articles included in the systematic review.

PT: Prospect Theory.

Systematic data of empirical studies.

N: sample size, M: mean; SD: standard deviation.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, J.G.-P.; methodology, M.M.-V. and J.G.-P.; software, M.M.-V., F.G.-S. and J.G.-P.; formal analysis, J.G.-P.; data curation, J.G.-P.; writing—original draft preparation, M.M.-V. and J.G.-P.; writing—review and editing, M.M.-V. and F.G.-S.; visualization, M.M.-V. and F.G.-S.; supervision, M.M.-V. and F.G.-S.; project administration, M.M.-V. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare that there is no conflict of interest.

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