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What is Case Conceptualization & How to Write it (With Examples)

Courtney Gardner, MSW

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The Ultimate Guide to Case Conceptualization: Our Top Tips, Outlines, and Real-life Examples

As a mental health counselor, case conceptualization is one of the most essential skills you can develop to understand your clients and find the most effective treatment. But for new counselors, the process can be overwhelming. How do you synthesize all the information from your intake and assessment into a cohesive case conceptualization? Which theoretical orientation fits best? What should you include in your conceptualization? Let's dive in and discover the secrets to developing killer case conceptualization skills!

What Is Case Conceptualization?

Case conceptualization is the process of understanding and interpreting a client's presenting problems within the context of their individual history, personality, and current circumstances. It involves gathering and organizing information about the client, identifying patterns and themes, and formulating a comprehensive understanding of the factors contributing to their difficulties. This understanding serves as the foundation for developing a treatment plan and guiding the therapeutic process.

Why Is Case Conceptualization Important to Mental Health Professionals?

Constructing a case conceptualization is crucial for mental health professionals as it helps them better understand their clients' perspectives and needs. Professionals can develop effective therapy outcomes by analyzing clients' experiences, thoughts, behaviors, environment, and biology. This enables them to identify suitable treatment options and establish  tailored treatment goals and interventions. A comprehensive approach is vital for providing evidence-based, client-centered therapy, which can lead to profound results, including improved insight, self-esteem, and motivation to make positive changes in their lives.

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How to Write a Case Conceptualization

To provide personalized treatment plans to your clients, it is essential to have a well-developed case conceptualization that helps you understand their mental health needs. You should include the following components early in creating your case conceptualization.

Client Information

Gather essential client information, including age, gender, relationship status, occupation, presenting problem, and relevant family and medical history.

Theoretical Orientation

Determine which theoretical approach fits their needs. This approach will guide the therapist to understand the client's symptoms and experiences through a particular lens. For example, a psychodynamic approach may focus on uncovering unconscious drives or past traumas, while a cognitive-behavioral approach looks at maladaptive thought patterns and behaviors.

If applicable, use the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-5) to identify appropriate diagnoses and diagnostic codes based on your client's symptoms. Explain your conclusions.

The Eight P’s of Case Conceptualization Framework

If you aim to create a comprehensive case conceptualization, you can employ the 8 Ps framework. The Eight Ps framework helps you organize and structure your thoughts and ideas concisely and quickly. Utilizing this framework allows you to analyze and evaluate a case from multiple perspectives and develop a fully formed and well-rounded understanding of the issues at hand.

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Presentation.

What symptoms or life difficulties brought the client in? How do they view these problems?

• Describe the client's symptoms, concerns, and goals.  Identify the main issues to address, such as depression, anxiety, trauma, or relationship difficulties. Consider the duration and severity of problems.

Predisposing Factors

What makes the client vulnerable to these problems? Genetics? Trauma?

• Consider the historical or biological factors involved in the current issue. This may include discussing the individual's developmental experiences, family history, or medical conditions. It is also essential to examine the client's natural tendencies, traits, and vulnerabilities that may make specific problems more likely.

Precipitating Factors

What recent events triggered the current problems? Loss of a job? End of a relationship?

• Investigate recent events that may have caused or intensified the client's presenting problem. Identify any losses, changes, or stressors in the client's life. These could include health issues, the end of a relationship, or the loss of a loved one. It is also crucial to examine how the client responded to these events.

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Do they live an active or sedentary lifestyle? Is their personality naturally more dependent or independent?

• Identifying predictable patterns in a person's thinking, feeling, acting, and coping reflects their baseline tendencies in stressful and non-stressful situations.

Perpetuating Factors

What factors in their lives maintain their problems? Avoidance? Unhelpful thoughts?

• Pinpoint and explore the habits, beliefs, or dynamics that maintain the problem. This means looking into their unhealthy coping strategies, cognitive distortions, relationship patterns, lack of social support, unstable living situations, and any other factors that may be contributing to the issue.

Protective Factors and Strengths

What strengths does the client have? A robust support system? Coping skills?

• Note their strengths, resources, and supports that can aid in their healing process. This may include skills, talents, social connections, access to healthcare, spirituality, and other positive factors supporting their treatment and recovery.

How will you address the problems and build on your client's strengths? Treatment modalities? Strategies?

• Establish goals and strategies considering the factors that may have caused or contributed to their condition. Identifying any protective factors the client may already have and developing interventions that build on them is also essential.
• Discuss specific interventions, referrals, and approaches. The plan should be comprehensive, regularly reviewed, and modified to ensure that it effectively reduces the client's distress, helps them change unhealthy patterns, builds new skills, and improves overall functioning. You should also consider your clinical decision-making during the initial planning stages.

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What's the likelihood of improvement with treatment?

• Forecast the outcome of treatment for a client based on a combination of risk factors, protective factors, the client's strengths, and their readiness for change. It would help if you discussed your initial impressions regarding the severity of the problem, the client's motivation for change, their responsiveness to intervention, and other relevant factors. You should also estimate the number of sessions required for treatment.

Tips for Mastering Effective Case Conceptualizations

Creating an effective case conceptualization requires a comprehensive, adaptable, and multidimensional approach. It involves analyzing the client's situation, embracing various perspectives, focusing on their strengths, and evolving throughout therapy. Stay curious, keep an open mind, and be willing to learn. Your clients can benefit significantly from these qualities.

Remember the following essential tips to hone your skills and make a lasting impact on your clients:

Focus on the client's strengths.

When assessing problems and symptoms, it is essential to identify your client's strengths, resources, and abilities and build on what's working to motivate change.

Look for themes and patterns.

As you gather information from your client, look for connections between their thoughts, feelings, behaviors, experiences, and relationships. Themes will emerge that shape your conceptualization.

Consider multiple perspectives.

Various theoretical orientations can be applied to comprehend a client's situation better. Exploring different perspectives can offer alternative insights into a case.

Be flexible.

It is essential to regularly revisit and update your case conceptualization as new information arises and as your client progresses.

Paint the whole picture.

An effective case conceptualization should consider cultural context, family and social relationships, medical history, life experiences, environment, and more, not merely focus on the client's symptoms or problems.

Discuss your conceptualization with colleagues.

Bouncing ideas off  other therapists  or discussing cases during supervision can provide valuable feedback and input, strengthening your case conceptualization from different perspectives.

Continuously evaluate your conceptualization.

During therapy, regularly review how well your understanding of the situation accounts for any new issues or lack of progress and adjust your approach accordingly. A successful interpretation should always remain an evolving theory.

Review research and theory.

It's necessary to base your case conceptualization on established theory and research to give credibility to your formulations and interventions. Keep yourself updated with the latest developments in psychotherapy and counseling.

Case Conceptualization Template

An efficient case conceptualization template helps you structure the essential components of a client's situation and establish the foundation for a focused treatment plan. By following this framework, you can guarantee that you have considered all the relevant factors and gained a comprehensive comprehension of the client and their requirements.

• Presenting problem : Briefly summarize the client's presenting issues and symptoms.
• History : Summarize relevant information about the client's family, developmental, medical, and mental health history.
• Functional analysis : Analyze the environmental, cognitive, and interpersonal factors contributing to or maintaining the client's problems. This includes triggers, consequences, and coping strategies.
• Conceptualization : Explain your theoretical model and how it helps you understand the client's difficulties. Identify key themes, patterns, and underlying processes.
• Goals : Outline the client's objectives for therapy and your treatment goals based on your conceptualization.
• Plan : Propose a treatment plan with specific interventions and strategies that address your conceptualization and the client's goals. Monitor and revise the plan as needed.

Sample Case Conceptualization #1: John

John is a 45-year-old accountant who has struggled with social anxiety and depression for most of his life. He finds it difficult to connect with others and lives a relatively isolated existence. John's anxiety causes distress in work and social situations where interaction with others is required. His anxiety and depressive symptoms have been exacerbated by several major life stressors over the past year, including a breakup with his long-term girlfriend and downsizing at his company, where he was laid off.

John sought counseling to help improve his social skills, increase confidence in social and work settings, and learn strategies to manage anxiety and depression better. Initial treatment focused on cognitive techniques to identify and reframe negative thought patterns related to social situations. Role-playing and exposure techniques were also used to help build comfort in engaging with others. John showed gradual improvement over 12 sessions. He reported feeling less anxious in work meetings and social encounters. John also started dating again and joined a local recreational sports league to increase social interaction.

John felt he had made good progress at termination but would benefit from occasional "booster" sessions to help maintain gains. Recommendations were made for John to continue practicing cognitive and exposure techniques, engage in regular exercise and social activity, and follow up with medication management as needed. John left treatment with improved coping strategies, a more balanced perspective, increased confidence in social abilities, and an overall brighter outlook.

Example of John's Case Conceptualization

I.  Presenting Problem

• John sought counseling to address social anxiety, depression, and low self-confidence that had been impacting his work and social life.
• His symptoms had worsened due to recent life stressors, including a breakup and job loss.

II.  Background Information

• John has struggled with social anxiety and depression for most of his life.
• He has difficulty connecting with others and lives an isolated existence.
• His anxiety causes distress in social and work situations involving interaction with others.

III.  Psychosocial History

• John has a history of social anxiety dating back to childhood.
• He has few close relationships and limited social support.
• Recent life stressors have exacerbated his symptoms.

IV.  Diagnostic Considerations

• Social Anxiety Disorder
• Persistent Depressive Disorder

V.  Treatment Plan

• Cognitive techniques to identify and challenge negative thoughts
• Exposure exercises to build social skills and confidence
• Medication management as needed
• Recommend regular exercise, social activity, and booster sessions
• Help John develop coping strategies and a more balanced perspective

Sample Case Conceptualization #2: Jane

Jane is a 32-year-old married woman who presented with anxiety, depression, and relationship issues. She reports a lifelong struggle with feelings of inadequacy and low self-esteem. Jane's anxiety and negative self-image have contributed to difficulty asserting herself in her marriage and feeling disconnected from her husband.

Jane's symptoms worsened after the birth of her first child two years ago. She experienced postpartum depression and anxiety, which left her feeling overwhelmed as a new mother. Her husband, John, works long hours and takes on few childcare responsibilities. This has caused conflict and resentment in their relationship.

Jane sought therapy to address her depression, anxiety, and relationship problems. She wants to improve communication with her husband and negotiate a more balanced division of labor. Treatment initially focused on helping Jane identify and challenge negative automatic thoughts. Psychoeducation about assertiveness and conflict resolution strategies was provided. Role plays were used to practice effective communication and negotiation skills with her husband.

With therapy, Jane showed improvement in her mood and confidence. She was able to initiate difficult conversations with her husband about household responsibilities and childcare. Through gradual progress, Jane and her husband have found some compromise. Jane plans to continue working on assertiveness and negotiating skills to improve their relationship further. Medication may be considered in the future if symptoms do not continue to improve with therapy alone.

Example of Jane's Case Conceptualization

I.  Presenting Complaints

• Relationship issues with husband

II.  History of Presenting Issues

• Lifelong struggle with low self-esteem and negative self-image
• Symptoms worsened after the birth of the first child two years ago
• Experienced postpartum depression and anxiety
• Felt overwhelmed as a new mother
• Husband takes on few childcare responsibilities, causing conflict
• Married for five years, one child, age two
• Husband works long hours
• Limited social support

IV.  Conceptualization

• Negative automatic thoughts contribute to anxiety and depression
• Difficulty asserting needs and communicating effectively with her husband stems from low self-esteem
• Unequal division of labor at home breeds resentment and relationship issues
• Cognitive techniques to challenge negative thoughts
• Role plays and assertiveness training to improve communication skills with husband
• Negotiation strategies for dividing household responsibilities more equitably
• Consider medication if symptoms do not improve sufficiently with therapy

Sample Case Conceptualization #3: Sally

Sally is a 45-year-old woman who presented with symptoms of anxiety, depression, and substance abuse issues. She reports a history of trauma from an abusive relationship in her 20s, which left her with trust issues and anxiety in intimate relationships.

Sally currently lives alone and works as an accountant. She struggles with loneliness and social isolation. She copes by drinking alcohol, up to a bottle of wine per night. Sally's alcohol use has negatively impacted her work and personal relationships.

Sally sought therapy to address her depression, anxiety, substance abuse, and difficulty forming close relationships. Treatment focused on building coping skills to reduce alcohol cravings and manage anxiety. Psychoeducation about trauma and its impact on trust was provided. Sally participated in exposure therapy to help her overcome social anxiety and develop healthier social connections. With treatment, Sally was able to reduce her alcohol intake to a safer level. She made progress in confronting trauma-related thoughts and feelings that had previously prevented her from forming close relationships. Sally plans to continue working on coping skills, exposure exercises, and managing trauma symptoms to fully recover from substance abuse and build a more fulfilling social life.

Example of Sally's Case Conceptualization

• Sally presents with symptoms of anxiety, depression, and substance abuse issues stemming from a history of trauma from an abusive relationship.

II.  History of the Presenting Problem

• Sally has struggled with loneliness and social isolation for years since the trauma, coping with excessive alcohol use. Her drinking has negatively impacted her work and relationships.

III.  Relevant Background Information

• Sally lives alone and works as an accountant
• She has difficulty forming close relationships due to trust issues from her past trauma
• Sally drinks up to a bottle of wine per night to cope with anxiety and depression
• Sally's anxiety, depression, and substance abuse are all interconnected and rooted in her unresolved trauma from the abusive relationship. Her social isolation and lack of coping skills have led to unhealthy drinking patterns.
• Reduce alcohol cravings through coping skill-building
• Provide psychoeducation about trauma and its impact
• Exposure therapy to overcome social anxiety and form healthier relationships
• Continue working on managing trauma symptoms to recover from substance abuse fully

FAQs: Your Top Case Conceptualization Questions Answered

Case conceptualization is a critical first step but can also feel overwhelming. Here are answers to some of the most frequently asked questions to help put your mind at ease.

How do I get started?

Begin by collecting information from intake forms, interviews, observations, and assessments. Look for patterns and connections to the underlying factors influencing your client's symptoms and behaviors. Identify strengths, weaknesses, thought processes, core beliefs, relationships, environment, medical issues, and life events.

What should I include?

A good case conceptualization includes a description of symptoms, diagnosis (if applicable), developmental history, family and relationship dynamics, traumas, coping skills, motivation for change, and goals. It helps determine the factors perpetuating the issues and maintaining the status quo.

How often should I update it?

A case conceptualization is a living document. As you learn more about your client through sessions, revisit and revise your conceptualization. Note any changes in symptoms or life events and adjust treatment plans accordingly. Regular updates, even minor ones, help ensure you accurately understand your client and provide the best care.

Does software help?

Case conceptualization software and apps can help organize and identify patterns in information. They can also assist you in collaborating with colleagues. However, remember that technology should supplement your clinical judgment, not replace it. Software is not capable of determining causation or proposing an effective treatment plan.

You now have what it takes to craft an effective case conceptualization. Armed with the necessary tools and examples, you can begin by considering the eight Ps - problems, precipitating events, predisposing factors, perpetuating factors, protective factors, prognosis, plan, and progress. Infuse each section with rich details about your client, including quotes and observations that bring the case to life. Examine examples from others while ensuring your conceptualization reflects your unique client and therapeutic approach. With regular practice, case conceptualizations will come naturally and aid you in selecting the best interventions and outcomes. Now, get out there and start conceptualizing.

Remember to keep learning and enhancing your practice with Mentalyc. Stay updated on the latest techniques, strategies, and tools by subscribing to our email newsletter. You'll receive emails with actionable therapy advice delivered directly to your inbox. Take  advantage of our app's free trial,  automatically creating progress notes based on your therapy sessions. With  AI-drafted notes , you can quickly review and finalize, saving time and effort. Join our growing community of therapists and mental health professionals dedicated to practical, compassionate client care.

Biopsychosocial Model and Case Formulation . (2022, January 2). PsychDB.  https://www.psychdb.com/teaching/biopsychosocial-case-formulation

Jagpat, E. (n.d.).  Anatomy of a Clinical Case Conceptualization . Psychology Oral Exam Preparation, Study Materials, Consultation & more.  https://psychologyoralexam.com/anatomy-of-a-clinical-case-conceptualization-psychology-oral-exam/

Sperry, L., & Sperry, J. (2016).   Case Conceptualization: Mastering this Competency with Ease and Confidence . APA PsycNet.  https://psycnet.apa.org/record/2012-34298-000

Zaheer, G. J., & Farmer, R. L. (2020, July 30).   Science-Based Case Conceptualization . National Association of School Psychologists (NASP).  https://www.nasponline.org/professional-development/a-closer-look-blog/science-based-case-conceptualization

All examples of mental health documentation are fictional and for informational purposes only.

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Case Examples

Examples of recommended interventions in the treatment of depression across the lifespan.

Children/Adolescents

A 15-year-old Puerto Rican female

The adolescent was previously diagnosed with major depressive disorder and treated intermittently with supportive psychotherapy and antidepressants. Her more recent episodes related to her parents’ marital problems and her academic/social difficulties at school. She was treated using cognitive-behavioral therapy (CBT).

Chafey, M.I.J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety , 26, 98-103.  https://doi.org/10.1002/da.20457

Sam, a 15-year-old adolescent

Sam was team captain of his soccer team, but an unexpected fight with another teammate prompted his parents to meet with a clinical psychologist. Sam was diagnosed with major depressive disorder after showing an increase in symptoms over the previous three months. Several recent challenges in his family and romantic life led the therapist to recommend interpersonal psychotherapy for adolescents (IPT-A).

Hall, E.B., & Mufson, L. (2009). Interpersonal Psychotherapy for Depressed Adolescents (IPT-A): A Case Illustration. Journal of Clinical Child & Adolescent Psychology, 38 (4), 582-593. https://doi.org/10.1080/15374410902976338

© Society of Clinical Child and Adolescent Psychology (Div. 53) APA, https://sccap53.org/, reprinted by permission of Taylor & Francis Ltd, http://www.tandfonline.com on behalf of the Society of Clinical Child and Adolescent Psychology (Div. 53) APA.

General Adults

Mark, a 43-year-old male

Mark had a history of depression and sought treatment after his second marriage ended. His depression was characterized as being “controlled by a pattern of interpersonal avoidance.” The behavior/activation therapist asked Mark to complete an activity record to help steer the treatment sessions.

Dimidjian, S., Martell, C.R., Addis, M.E., & Herman-Dunn, R. (2008). Chapter 8: Behavioral activation for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 343-362). New York: Guilford Press.

Reprinted with permission from Guilford Press.

Denise, a 59-year-old widow

Denise is described as having “nonchronic depression” which appeared most recently at the onset of her husband’s diagnosis with brain cancer. Her symptoms were loneliness, difficulty coping with daily life, and sadness. Treatment included filling out a weekly activity log and identifying/reconstructing automatic thoughts.

Young, J.E., Rygh, J.L., Weinberger, A.D., & Beck, A.T. (2008). Chapter 6: Cognitive therapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 278-287). New York, NY: Guilford Press.

Nancy, a 25-year-old single, white female

Nancy described herself as being “trapped by her relationships.” Her intake interview confirmed symptoms of major depressive disorder and the clinician recommended cognitive-behavioral therapy. 

Persons, J.B., Davidson, J. & Tompkins, M.A. (2001). A Case Example: Nancy. In Essential Components of Cognitive-Behavior Therapy For Depression (pp. 205-242). Washington, D.C.: American Psychological Association. http://dx.doi.org/10.1037/10389-007

While APA owns the rights to this text, some exhibits are property of the San Francisco Bay Area Center for Cognitive Therapy, which has granted the APA permission for use.

Luke, a 34-year-old male graduate student

Luke is described as having treatment-resistant depression and while not suicidal, hoped that a fatal illness would take his life or that he would just disappear. His treatment involved mindfulness-based cognitive therapy, which helps participants become aware of and recharacterize their overwhelming negative thoughts. It involves regular practice of mindfulness techniques and exercises as one component of therapy.

Sipe, W.E.B., & Eisendrath, S.J. (2014). Chapter 3 — Mindfulness-Based Cognitive Therapy For Treatment-Resistant Depression. In R.A. Baer (Ed.), Mindfulness-Based Treatment Approaches (2nd ed., pp. 66-70). San Diego: Academic Press.

Reprinted with permission from Elsevier.

Sara, a 35-year-old married female

Sara was referred to treatment after having a stillbirth. Sara showed symptoms of grief, or complicated bereavement, and was diagnosed with major depression, recurrent. The clinician recommended interpersonal psychotherapy (IPT) for a duration of 12 weeks.

Bleiberg, K.L., & Markowitz, J.C. (2008). Chapter 7: Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: a treatment manual (4th ed., pp. 315-323). New York, NY: Guilford Press.

Peggy, a 52-year-old white, Italian-American widow

Peggy had a history of chronic depression, which flared during her husband’s illness and ultimate death. Guilt was a driving factor of her depressive symptoms, which lasted six months after his death. The clinician treated Peggy with psychodynamic therapy over a period of two years.

Bishop, J., & Lane , R.C. (2003). Psychodynamic Treatment of a Case of Grief Superimposed On Melancholia. Clinical Case Studies , 2(1), 3-19. https://doi.org/10.1177/1534650102239085

Several case examples of supportive therapy

Winston, A., Rosenthal, R.N., & Pinsker, H. (2004). Introduction to Supportive Psychotherapy . Arlington, VA : American Psychiatric Publishing.

Older Adults

Several case examples of interpersonal psychotherapy & pharmacotherapy

Miller, M. D., Wolfson, L., Frank, E., Cornes, C., Silberman, R., Ehrenpreis, L.…Reynolds, C. F., III. (1998). Using Interpersonal Psychotherapy (IPT) in a Combined Psychotherapy/Medication Research Protocol with Depressed Elders: A Descriptive Report With Case Vignettes. Journal of Psychotherapy Practice and Research , 7(1), 47-55.

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Case conceptualization: Key to highly effective counseling

By Jon Sperry and Len Sperry

December 2020

I n their first session, the counseling intern learned that Jane’s son had been diagnosed with brain cancer. The therapist then elicited the client’s thoughts and feelings about her son’s diagnosis. Jane expressed feelings of guilt and the thought that if she had done more about the early symptoms, this never would have happened to her son. Hearing this guilt producing thought, the intern spent much of the remaining session disputing it. As the session ended, the client was more despondent.  

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.

Presentation

Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.

Predisposition

Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.

Precipitants

Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.

Perpetuants

Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.  

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids cl oseness to avoid perceived harm

Predisposition:

• Biological: Paternal history of anxiety
• Psychological: Views herself as inadequate and others as critical; deficits in assertiveness skills, self-soothing skills and relational skills
• Social: Few friends, a history of social anxiety, and parents who were highly successful and critical
• Cultural: No acculturative stress or cultural stressors but from upper-middle-class socioeconomic status, so from privileged background — access to services and resources

Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation) . A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant) . She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern) . Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants) .

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors) .

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological) ; she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological) ; she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social) . Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural) .

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment) .

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis) .

Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence .

Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at [email protected] or visit his website at drjonsperry.com .

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Person-Centered Therapy Case Study: Examples and Analysis

Introduction

Welcome to The Knowledge Nest's in-depth exploration of person-centered therapy case study examples and analysis. We aim to provide you with comprehensive insights into the therapeutic approach, techniques, and outcomes associated with person-centered counseling. Through real-life case scenarios, we demonstrate the effectiveness of this humanistic and client-centered approach in fostering personal growth and facilitating positive change.

Understanding Person-Centered Therapy

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a compassionate and empathetic therapeutic approach developed by the influential psychologist Carl Rogers. This person-centered approach recognizes the profound significance of the therapeutic relationship, placing the individual at the center of the therapeutic process.

Unlike traditional approaches that impose solutions or interpretations on clients, person-centered therapy emphasizes the innate human capacity to move towards growth and self-actualization. By providing a supportive and non-judgmental environment, therapists aim to enhance clients' self-awareness, self-acceptance, and self-discovery. This holistic approach has proven to be particularly effective in addressing a wide range of mental health concerns, empowering individuals to overcome challenges and achieve personal well-being.

Case Study Examples

Case study 1: overcoming social anxiety.

In this case study, we explore how person-centered therapy helped Sarah, a young woman struggling with severe social anxiety, regain her confidence and navigate social interactions. Through the establishment of a strong therapeutic alliance, her therapist cultivated a safe space for Sarah to explore her fears, challenge negative self-perceptions, and develop effective coping strategies. Through the person-centered approach, Sarah experienced significant improvements, enabling her to participate more actively in social situations and regain a sense of belonging.

Case Study 2: Healing from Trauma

John, a military veteran suffering from PTSD, found solace and healing through person-centered therapy. This case study delves into the profound transformation John experienced as he worked collaboratively with his therapist to process unresolved trauma. By providing unconditional positive regard, empathetic listening, and genuine empathy, the therapist created an environment where John felt safe to explore his traumatic experiences. With time, he was able to develop healthier coping mechanisms, embrace self-compassion, and rebuild a sense of purpose.

Case Study 3: Enhancing Self-Esteem

In this case study, we examine Lisa's journey towards building self-esteem and self-worth. Through person-centered therapy, her therapist empowered Lisa to identify and challenge deeply ingrained negative self-beliefs that inhibited her personal growth. By offering non-directive support, active listening, and reflective feedback, the therapist enabled Lisa to develop a more positive self-concept, fostering increased self-esteem, and self-empowerment.

Analysis of Person-Centered Therapy

The therapeutic relationship.

Person-centered therapy places profound importance on the therapeutic relationship as the foundation for positive change. The therapist cultivates an atmosphere of trust, respect, and authenticity, enabling the individual to feel heard and valued. By providing unconditional positive regard, therapists create a non-judgmental space where clients can freely explore their thoughts, emotions, and experiences.

Client-Centered Approach

The client-centered approach encourages individuals to take an active role in their therapeutic journey. The therapist acts as a facilitator, guiding clients towards self-discovery and personal growth. By allowing clients to set the agenda and directing the focus of sessions, the person-centered approach acknowledges the unique needs and perspectives of each individual.

Empowering Self-Awareness and Growth

Person-centered therapy seeks to unlock individuals' innate capacity for self-awareness and personal growth. Through empathic understanding, therapists support clients in gaining insight into their emotions, thoughts, and needs. This heightened self-awareness helps individuals develop healthier coping mechanisms, make meaningful choices, and move towards a more fulfilling life.

Person-centered therapy, as exemplified through the case studies presented, offers a powerful and transformative path towards holistic well-being and personal growth. The Knowledge Nest is committed to providing a platform for sharing knowledge, experiences, and resources related to person-centered counseling. Together, we strive to facilitate positive change, empower individuals, and create a more compassionate and understanding society.

Explore more case studies and resources on person-centered therapy at The Knowledge Nest to discover the profound impact of this therapeutic approach.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

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How to write counseling case studies

• Jan 31, 2021
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As a psychotherapy or counseling student, you are very likely to come across such written assignments as counseling case studies . As this is a very particular type of academic assignment, we created this guide to help you write psychotherapy case studies as a professional. 

A counseling case study is basically a simulation of your future work as a counselor. You have got a case about a person who has some psychological or mental challenges. You are provided with a description of the situation, the client’s complaints, behavior, some environmental factors like family, work, ethnic, cultural, and socio-economic factors, and you need to present your opinion about the situation and a tentative treatment plan. 

So essentially, you need to imagine yourself as a psychotherapist who works with this client and knows how to treat him. Therefore in your paper, you cannot just write irrelevant information such as definitions of mental diseases, history of counseling, or other side digressions just to fill up the required word count. This approach may work for many types of essays, but not for counseling case studies.  When writing case studies on psychotherapy, you need to be very on point. 

Your paper should contain three basic sections:

• Your analysis about the client’s situation;
• Diagnosis or summary/interpretation of the client’s problem from a particular theoretical standpoint or from an integrative perspective
• Interventions that might help the client based on your analysis. 

Your counseling case study should contain the analysis of the client's situation, assessment or diagnosis, and treatment plan containing proposed interventions and reflection on the therapeutic process. 

Keep in mind that the basic principle of academic paper writing is: KNOW WHAT YOU WRITE . That means know what you are required to write (make sure you understand the assignment and read the case carefully) and have the background knowledge about the theory and practice of psychotherapy, general counseling theories or a specific theory, and therapeutic techniques and interventions. 

For some people, such an assignment may seem overwhelming as you are not a working counselor yet and you are not sure how to tackle the client’s problem. But do not panic, just follow the steps below to produce a high-quality counseling case study. 

1.    Read your assignment and the case description carefully

Clarify all the terms you encounter in the case.  Make sure you know what theory of psychotherapy you are expected to follow in your diagnosis and treatment plan. If no theoretical approach is mentioned in your assignment, check if you have covered any particular theories in your classes.

If you are not sure what a theory of psychotherapy is, it’s a particular approach to interpret psychological and mental problems. The first theory of psychotherapy was psychoanalysis developed by Sigmund Freud. Its theoretical foundation relied on distinguishing three parts of the mind: ego, superego, and id; recognizing the role of the subconscious with its instincts and drives in psychological conflicts; interpreting maladaptive behavior through the lens of ego defenses; recognizing the role of early childhood experiences, particularly childhood traumas, in the pathophysiology of mental problems.  Later, many other theories of counseling were developed, such as Adlerian, existential, humanistic and person-centered, behavior (BT), cognitive-behavior therapy (CBT), Gestalt therapy, reality, feminist, narrative, solution-focused brief therapy, family systems therapy , and many others. So if earlier in the class, you covered humanistic counseling, you can use the humanistic theoretical approach in your case analysis (unless, of course, your assignment clearly states what theory you need to follow). 

2.    Review the textbook chapters on that theory paying attention to particular approaches to diagnosis and therapeutic techniques.

Theory is important as different theoretical frameworks interpret the same situation in a different way. For example, the same symptoms could be interpreted as defenses caused by childhood trauma in psychoanalysis, malfunctioning behavioral patterns in Behavior therapy, dysfunctional cognitive schemes in CBT, unfinished business in Gestalt, destructive environmental factors in feminist therapy, being stuck in a pattern of living a problem-saturated story in narrative therapy, and so on. 

3.    Re-read the case again paying attention to special terms

and see if you now understand the meaning of these terms after studying the literature. 

4.    Read additional resources (optional)

If you still have doubts about the case and how to proceed with it, you might need additional resources, either provided by your teacher or found on the Internet. If you have a specific psychotherapeutic theory to follow for your case, you can google “assessment and treatment in [your theory]” and search for books, worksheets, or articles. 

5.    Summarize the client’s situation in the case.

In this stage, we start writing up the draft of the case analysis. Describe the gist of the client’s problem as he sees it and as you can grasp from the description of his behavior, thoughts, and feelings in the case. If you can locate it in the case, summarize his family situation, relationships, the family of origins, and work relations . Also, note if any sociocultural factors, like race, religion, ethnicity, gender, income level, sexual orientation, or neighborhood , may have impacted the client and his significant relations. Note if the client has previously done efforts to deal with his problems and what these efforts were. 

6.    Formulate a diagnosis for the client.

This section will often require you to provide a diagnosis according to DSM diagnostic criteria or formulate a problem according to the conventions of your counseling theory. Some theoretical frameworks, like Narrative or Feminist therapy, do not make diagnoses in working with clients as they view clinical diagnosis as a pathologizing, discriminatory and condescending practice that skews power balance in favor of the therapist. So if you are writing the case study within one of these paradigms, you will not have to provide a diagnosis for the client. However, you will still have to make a sort of assessment. While diagnosis involves identifying specific mental disorders based on patterns of symptoms, for assessment , you need to point out the client’s main problem and identify the main factors of the client’s life that you think might be contributing to this problem.

If you need to provide the diagnosis according to DSM-V manual, pay attention to the Differential diagnosis section for each disorder description. If the client’s symptoms initially look like major depressive disorder, you can consult the differential diagnosis section in the major depressive disorder chapter to see if there are alternative explanations fitting the client’s symptoms. Thus, for major depressive disorder, the alternatives may be substance/medication-induced depressive or bipolar disorder, mood disorder due to another medical condition, ADHD, adjustment disorder with depressed mood, and sadness. Check the diagnostic criteria for all these disorders to find which one fits better. Some of the assignments will require you to spell out how many symptoms fit the criteria of the disorders, and name these symptoms.

7.    Outline the developmental context of the problem.

Write how the client’s problem developed over time. Consider if early childhood experiences, the family of origin, or family structure may have contributed to this problem. Has a similar problem been experienced by some family member before? Have environmental and socio-economic factors , like income level, race, ethnicity, religion, sex, sexual orientation, or any others, contributed to the development of the problem?  How do these developmental factors interact with the current stressors and conflicts to shape the client’s worldview? Does the client have social support or safety net to rely on? In some theoretical approaches, you will also have to identify the client’s pathogenic or irrational beliefs about himself (like BT and CBT), maladaptive styles of functioning (Gestalt, psychoanalysis), or internalized dysfunctional cultural narratives (narrative and feminist therapies). 

8.    Propose interventions and techniques that might benefit the client.

If you follow a specific theory, this assignment is not that hard. Just go to the textbook chapter of your theory, check the techniques and interventions, and choose the ones that are appropriate for your situation. But do not just mechanically copy the list of techniques from the textbook. Imagine yourself sitting with the client and having a counseling session with them. Where would you start? If you are at loss, remember that almost all theories start with establishing a contact, creating a therapeutic relationship with the client. You might start by explaining your role and responsibilities, the client’s rights and the process of therapy, and getting informed consent from the client. Listen to his story attentively and respectfully, learn reflective listening , suspend judgment about the client, show empathy . These are basic things that almost all therapists irrespective of their theoretical orientation and client’s problem, use. To these, you will add specific techniques from your theoretical approach or techniques that are normally used for similar problems. 

9.    Add reflections on the therapeutic process.

This section is not required in all case studies, but it’s often present since you need to be aware of this aspect as a future therapist. Here, write what you think about the client. Does she and her problems engage you emotionally? How might your feelings help or hinder the therapeutic process? Is there room for countertransference (when a client’s problem triggers an emotional response from you connected with your previous experience or your own problem). How might this client perceive you? How might her feelings help or hinder the therapeutic process? What challenges you might face while working with the client? What traits of your personality or any previous experience might help you establish trust and connection? 

Final thoughts

This is the general outline of all counseling case studies. The requirements might vary from case to case, but these steps are pretty much essential for a solid analysis of a client’s situation in a therapeutic setting. All these steps might seem overwhelming to you, but do not despair. To be successful, it is essential to understand the requirements and the case, have knowledge about your theory and counseling approach, and then use your brains to reflect on the given case using common sense, knowledge from the textbook, and your imagination of how you would work with a person presented in the case. As you see, in this paper there is not much room for paraphrasing or filling the space with irrelevant information. Everything must be very to the point. The only place where you can use some rewriting is the DSM diagnosis section, ONLY if the teacher asks you to note down all the symptoms that fit the diagnosis. Then you can take those symptoms from the diagnostic criteria of the disorder and slightly paraphrase them. The rest of the paper is your own reflection about the case, the client, and the ways to help him . If you feel intimidated, do not worry. Just start doing these cases, and you will get better with time. 

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041 – Writing Case Studies – Carl Rogers’ 19 Propositions – Counselling Skills

In episode 41 of the Counselling Tutor Podcast, Rory Lees-Oakes and Ken Kelly describe how to write a case study. ‘Theory with Rory’ looks at how best to apply the 19 propositions when writing case studies and assignments. Last, the presenters talk about diversity in the counselling room.

Writing Case Studies (starts at 3.26 mins)

Ken and Rory offer a number of tips on writing case studies as a student:

• Always check the criteria set by your awarding body before you start writing.
• Open the case study with a ‘pen portrait’ of the client – e.g. age, gender and presenting issue.
• Continue by describing the client’s counselling journey, from start to finish.
• Depending on the criteria you are working to, there are various themes you can develop – for example, ethics , the theory of your modality, and your self-awareness during the work.
• It is always good to reflect on your own learning from your sessions with the client, and how you might approach things differently in future.

Carl Rogers’ 19 Propositions (starts at 13.51 mins)

The 19 propositions were developed by Carl Rogers, the founder of person-centred therapy. They describe his theory of personality, expressed in terms of how a human being perceives the world (i.e. phenomenology). This part of person-centred theory is often seen as particularly hard to ‘decode’. Rory has done so previously in Counselling Tutor Podcasts 13 and 14 . One key tip he offers when reading Rogers’ original wording is to swap the word ‘organism’ for ‘person’.

Rory offers three insights into how you can make maximum use of the 19 propositions when writing case studies and assignments. For example, you can use this theory to:

• evidence how clients engage with their incongruent selves
• describe how, in making sense of their reality, clients can transcend it (as the philosopher Edmund Husserl believed that once indivuduals understand their reality, they can then transcend it)
• explain how clients engage with their truth and what changes they make as a consequence of that.

Key to all these is to use client statements from counselling interactions to illustrate your points.

For more information, you can download Rory’s handout, ‘Three Positions in Phenomenology : The 19 Propositions’.

Free Handout Download

19 Propositions: Three Positions in Phenomenology

Counselling Skills (starts at 19.40 mins)

In counselling training, it is harder to demonstrate our use of skills than our understanding of theory (which can be written about in assignments). Because our work with clients is subject to confidentiality, we must showcase our grasp of skills through simulated sessions with peers. This can feel rather artificial, with a pressure to somehow slot in every skill in order to meet the criteria.

Ken’s new book, Basic Counselling Skills: A Student Guide is a great resource for skills development at all qualification levels. Uniquely, this includes links to online audio recordings of skills demonstrations. The effect of each skill is explored. As shown in research by Catherine Goldsmith at the University of Manchester, which led to the dodo bird conjecture , the key to effective therapy is primarily the relationship between the patient and therapist. Good counselling skills are key to building this relationship.

Rogers used to audio record client sessions and listen back to these for learning. Recording is really useful for student counsellors; Ken strongly recommends doing so as much as possible (with client consent). Voice recorders can be purchased inexpensively these days.

Links and Resources

Counselling Study Resource

Counselling Tutor Facebook group

Counselling Tutor website

Basic Counselling Skills: A Student Guide

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Person-Centered Therapy Case Study: Examples and Analysis

By: Tasha Kolesnikova

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a form of psychotherapy developed by prominent American psychologist Carl Rogers throughout the 1940s to the 1980s. This type of therapy is a humanistic approach and was seen as revolutionary as most psychotherapies before its emergence was based on behaviorist and psychodynamic approaches. The humanistic approach directly contradicts and contrasts core techniques and models of other approaches that were commonly used at the time.

What Is Person-Centered Therapy?

5 characteristics of the fully functioning person, causes of incongruence, person-centered therapy in practice, person-centered case study, person-centered treatment plan.

Nowadays, the fundamental modalities of person-centered therapy are widely used in modern counseling practices in combination with other techniques and therapies. Rogers is often considered the father of all humanistic schools of therapy, as many new therapies have since stemmed from his work. 

Students can use this article as a resource to help them with an academic essay  about person-centered therapy. 

Person-centered therapy focuses on facilitating  self-actualization .  The therapy is built upon the fundamental ideology that human beings have an innate desire and ability to be the best they can be and live happy, fulfilling lives. An individual must set their own goals, and proceed to approach them in their own way. Once these goals have been met, self-actualization is also achieved and, as a result, they will become a  fully functioning person . 

It also promotes the notion that all individuals have the ability to cope with their problems and possess the potential for change. These abilities are unique to each individual, and therefore, everyone has the power to formulate appropriate solutions to help themselves navigate and manage their lives.

Positive growth can be achieved when an individual has positive regard for themselves and from others. Once optimal levels are reached, the individual will become fully functioning. Under this self-concept, it is believed that every individual has:

• the capacity for self-awareness
• the need for meaning in their life
• the need for balancing freedom and responsibility

The key part of the person-centered approach is to assist individuals in self-discovery and self-acceptance by providing sufficient conditions that help resolve incongruence between themselves and their experiences.

According to Rogers, a fully functioning person has the following five characteristics:

• They are  open to new experiences , both positive and negative. They accept that life can sometimes be painful, but they have healthy abilities to cope and learn from them.
• They are  mindful and focus on present  experiences without preconceptions from previous experiences. They do not dwell on the past or obsess about the future.
• They are  aware of and attentive to facts ,  feelings, and gut reactions . Unity of all three allows them to be true to themselves and thus have the confidence to make the right decisions. If the wrong choice is made, they will be able to accept it and learn from it.
• They are  willing to take risks and be adaptive . They will seize healthy and appropriate opportunities for growth.
• They  have a sense of contentment  and a desire for new challenges and experiences.

Each of these characteristics is achieved through congruence of the self.

An individual tends to struggle with becoming a fully functional person, mostly due to incongruence. Incongruence is usually caused by encountering conditional worth or conditional love at some point, often during childhood.

If love and worth are dependent on meeting specific expectations and withdrawn when these expectations were not met, the individual will suffer from anxiety. This anxiety leads to a feeling of the unified self-being under attack. To relieve this anxiety, the individual will engage in detrimental methods such as denial and defensiveness.

Another cause is frustrated basic impulses that lead to negative feelings and poor social skills.

Individuals receiving person-centered therapy are referred to as clients rather than patients. This is in line with the overall concept that therapy is a shared journey between two people rather than the therapist or counselor treating or giving the advice to solve problems. The client is regarded as the expert of themselves and has all the answers to their own problems required within them.

Sufficient core conditions required for therapeutic change under person-centered therapy are outlined as follows:

• Psychological contact  - a mutually respectful relationship between the counselor and patient must exist, where both parties feel equally important.
• Client incongruence  – the client must experience distress caused by incongruence between their experiences and awareness. They are vulnerable and or anxious.
• Therapist congruence or genuineness  – sometimes referred to as being authentic. The therapist must be aware of their active participation and be deeply involved, becoming congruent with the therapeutic relationship.
• Therapist unconditional positive regard  – the therapist or counselor must have a non-judgmental stance, so the counselor does not impose any conditions of worth.
• Therapist empathy  – the therapist or counselor must effectively and accurately communicate their empathic understanding of the client's frame of reference. Presenting problems from another perspective can also help the client gain a new point of view to solving them.
• Client perception  – the client must perceive and appreciate this empathy and acceptance from their therapist or counselor and develop positive self-regard to a minimal degree.

It is interesting to note that Rogers viewed both approval and disapproval shown towards an individual to be disruptive to therapeutic change. The role of the therapist is to provide a caring and accepting environment conducive to giving clients the freedom to explore areas of their lives in ways they were previously denied or distorted. 

Unlike other therapies, Person-centered therapy does not have many set techniques. This Is because therapy sessions are largely directed by the individual. The counselor's or therapist's job is to create a safe environment that facilitates congruence and form a therapeutic alliance with the individual.

Because of this, a defining technique used during person-centered therapy is  non-directiveness . This is achieved by:

• giving no advice
• asking no questions
• giving no interpretations
• allowing clients to set their own goals

Another technique used during therapy sessions is  active listening . This is achieved by:

• paraphrasing
• summarizing

It was theorized that the client will initially be closed, not open to experiences, and have little to no self-awareness. But once therapy is completed, all these obstacles will be addressed and reversed due to gaining positive self-regard.

There are many advantages in the techniques used during person-centered therapy. However, some concerns have also been raised about the approach:

• Non-directiveness  - idea of non-directiveness has been largely debated. Some have argued that therapy by nature will always be directed in some capacity. Furthermore, bias can never be completely eliminated. Therefore, unconscious or unintentional bias can cause direction.
• Inefficient  – person-centered therapy can take an unnecessarily long time due to the lack of structure and non-directiveness. For fear of intervening with progress, therapists may deliberately withhold solutions or advice from a client, and it may take longer than necessary to reach that solution, if at all.
• Frustration  – being non-direct can understandably cause frustration in some clients who may be seeking advice or opinions.
• Disorder specific  – Rogers originally claimed that Person-centered therapy could treat all mental health disorders, but research has shown this is not the case.

Jane's phenomenological worldview causes her to be incongruent with her true self and what she believed is expected of her. Expectations imposed upon her are unrealistically high, and fear of not meeting those standards has caused her incongruent distress. Subsequently, this has created a condition for her self-worth.

These expectations are a direct result of traumatic stress stemming from culture, religion, and loved ones. In her phenomenological world, she will never be good enough as a daughter, mother, wife, Catholic, or accountant. She feels she constantly lets everyone down and can never gain approval from those whose opinions she cares about.

Trying harder to please and meet everyone's expectations takes her further away from wholeness and true self-worth. She has lost confidence in her ability to make good decisions and constantly seeks outside direction on how she should act. This low self-esteem will hinder any feelings of success and satisfaction.

She is aware that how she handles situations as it stands is not working but fails to see the situation from another perspective or figure out new solutions.

This is a classic example of a client that may benefit from person-centered therapy. We can understand that although Jane feels these pressures of meeting rejection and disapproval, she still has the potential for self-actualization.

This is evidenced by her independent decisions of marrying a spouse outside her religion and studying accountancy against her family's wishes. The act of seeking therapy confirms her desire for growth and change for a better life.

Jane has risen above adversity on multiple occasions in life. She has achieved academically, personally, and professionally but the lack of caring relationships has distorted her ability to recognize and accept her success and potential. This has deterred her from achieving higher levels of self-actualization. Jane must take new risks to attain the growth she seeks. 

For treatment to be effective, the core conditions must be met. The formulation was as follows:

• Undertaking person-centered therapy, the therapist will provide an optimal therapeutic environment where her actualizing tendencies can flourish.
• Through active listening and empathy, the therapist and Jane will build a trusting therapeutic alliance and further clarify her thoughts and feelings. Being able to work out problems and breaking them down, Jane will no longer view them as insurmountable as she did before.
• Unconditional positive regard will install confidence in Jane as a competent person capable of making decisions and problem solving on her own. By increasing trust in herself, she reduces the control others have over her and will begin to believe in her own self-worth.
• Consistency and genuine rapport between Jane and the counselor will allow her to feel that the ideas and actions developed during sessions are authentic, dependable, and can be replicated outside in the real world.
• Jane's newfound view of the world will lead to her trying out new approaches to problems. She will continue to report back on her progress in integrating these new approaches. She will eventually come to recognize that she is capable of independently achieving success and overcoming failure.
• Jane will continue these practices until she has reached self-actualization and becomes a fully functional person.

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20 Useful Counseling Forms & Templates for Your Practice

Part of this relationship includes building an appropriate therapeutic framework that provides “a safe and consistent professional structure for the therapeutic work to take place” (Knox & Cooper, 2015, p. 1).

As with any other professional service, especially one that focuses on client wellness and safety, procedures, policies, and forms are required to ensure appropriate record keeping and handling of the client and their information.

This article introduces templates and forms that support the intake, assessment, referral, and other key stages of the counseling journey.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

Conducting intake sessions: 3 forms & templates, best counseling & assessment forms (+ templates), a look at informed consent forms: 3 samples, 2 useful referral forms, telehealth counseling forms: 5 helpful templates, 2 best forms for group counseling sessions, positivepsychology.com’s relevant resources, a take-home message.

Counseling typically begins with the intake and the assessment process. Together, they provide crucial opportunities to capture information regarding the client, their needs, and their hopes for treatment (Corey, 2013).

The intake and assessment forms can be merged – their degree of information overlaps and they’re both used in early sessions – or they may remain separate, even if only in terms of form completion.

This article has kept the forms distinct for convenience and clarity. We use the intake form to capture the client’s personal details and their initial thoughts on why they seek treatment, and this may be completed before their first session with the counselor.

In the next section, we introduce sample assessment forms, typically used in the client’s first (and perhaps second) session to assess their situation, concerns, and goals in more depth and form a clearer and shared understanding of where they are and how they may need help.

Treat the intake and assessment forms as templates, designed to be modified as required, and either kept separate or combined depending on the counseling approach , techniques adopted, and needs of the client.

General counseling intake

Getting started with new clients and structuring the first counseling sessions requires an initial understanding of their background, concerns, and primary thoughts on how and where they require help and support (Cochran & Cochran, 2015).

The New Client Intake Form can be completed before the first session to capture personal information relating to the client, such as:

• Name, age, and contact details
• Employment status
• Reasons for seeking help
• Physical and mental health history
• Counseling goals

Employee counseling intake

Employee counseling can take many forms and may be performed face to face, by telephone, and even live chat or email. It may be offered in response to (Lagerveld & Blonk, 2012):

• An incident at work
• Employee mental health concerns
• Returning to work after a period off
• A member of staff seeking new opportunities
• Concerns over bullying

The Employee Counseling Intake Form is written with a staff member seeking change in mind, but it can equally be used for other purposes. The employee will typically complete it before meeting a counselor and includes:

• Limited personal information
• Contact details
• Occupation and status
• Manager/supervisor name
• Educational, training, and employment history
• Change sought
• Reason for attending counseling

Couples counseling intake

Couples counseling is “not the same thing as individual counseling, with two clients in the room instead of one” (Williams, 2012, p. 1). The therapeutic relationship with the client will be different, and it is crucial to understand the needs, concerns, and personal history of each individual and the couple as a whole.

Both members of the relationship complete the Couple Counseling Intake Form , and while asking the same questions, the form will often surface different points of view and insights.

Information requested typically includes:

• Personal details (e.g., name, age, etc.)
• Status of the relationship
• Length of relationship
• Reason for seeking help
• Relationship strengths
• Relationship risks and concerns

The following forms (some general, others with specific uses) provide templates for the initial and ongoing assessment of a client and their needs. There is some overlap with the intake forms, but they offer a continuing opportunity to gather additional and valuable information, particularly in the early sessions.

Employee assessment

Whether performed before or during an early session, it is important to understand the reasons for the employee attending or being referred to counseling.

The Employee Counseling Assessment Form can be helpful for understanding and discussing an issue or event that has arisen at work that has led to an employee being referred for counseling. It continues on from the original employee intake form, asking:

• Reason for referral
• Details of the incident and witnesses
• Corrective actions agreed upon between counselor and employee
• Employee comments
• Consequences of not taking the agreed-upon steps

Couples counseling assessment

It can be helpful for the counselor and a powerful and rewarding exercise for the couple to review how they met (Williams, 2012).

Use the Couple Counseling Assessment  and/or the Couple Counseling Relationship History Assessment to review and assess how the couple met, what drew them to each other, and their current degree of difficulties.

Each member of the relationship may have very different answers in response to questions, such as:

• How did you meet?
• What first attracted you to your partner?
• What continued to attract you to your partner?
• What do you think first attracted them to you?
• What do you think continued to attract them to you?
• Describe your early years together.
• How were things better then?
• How are things better now?
• What current stressful events or situations exist?
• How satisfied are you with your marriage?
• What areas require focus?

Reviewing the answers makes it possible to develop a plan and a commitment to daily caring behaviors.

Assessment of skills

Sometimes clients lack the skills needed to manage difficult situations or problems (Nelson-Jones, 2014).

Through considering and discussing a problem or situation that has been upsetting, it is possible to identify insufficiently strong skills and potential goals for counseling.

Use the Assessment of Insufficiently Strong Skills worksheet to reflect on and capture the nature of the problem and where there are opportunities to improve, including mind and communication skills .

Work with the client during the session to describe the problem or situation and create goals.

Capturing such areas for skill improvement will direct future counseling sessions.

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Counselors must be sufficiently competent to offer their services to the client. They must be qualified or undergoing supervision, trained according to the guidelines and mandates in the location they are practicing, self-aware, and have worked out their own issues (Sommers-Flanagan & Sommers-Flanagan, 2015).

The idea and practice of informed consent is closely aligned with counselor competence, where “clients have the right to know your training status and the supervision arrangements you have” (Sommers-Flanagan & Sommers-Flanagan, 2015, p. 19).

The counselor should share their qualifications, the techniques they will be using, and how long counseling will likely last.

The following is a selection of examples of informed consent. There are many others available that may be suitable for your needs and can be found via a quick online search.

• Counseling and psychotherapy – It is important that the client is made aware that the counselor is licensed, the number and length of sessions, and how to make or cancel appointments. And while confidentiality is vital, the client typically gives consent for the counselor to act when they or others are in danger or at risk of harm.
• Informed consent for therapy agreement – Informed consent agreements will often clarify the nature of the client’s voluntary participation and their commitment to attend appointments on time. It is also essential to state that while therapy is usually beneficial, there are no guarantees that the client will get better.
• Counselor in training – When counselors are in training and dealing with clients (sometimes children), it is vital all parties are made fully aware they are currently under supervision and yet to qualify.

These three samples of informed consent are not exhaustive and must be created in line with local laws and guidance, and safeguard the rights and needs of the client at all times.

General Referral for Counseling

The General Referral for Counseling form can be completed by a concerned other party or by the client themselves if self-referring and includes:

• Personal details, including name, address, age, etc.
• Reasons for referral, significant incidents, etc.
• Details of the person referring (such as title, role, contact details)
• Examples of behavior
• Actions taken so far
• Urgency of referral

Student Referral to School Counselor

School and college years can be stressful for students, and there may be times when they are unable to cope. Warning signals may include (Anderson University, n.d.):

• Excessive procrastination
• Poorly presented work
• Infrequent class attendance
• Trouble concentrating
• Disruptive behavior
• Appearing overly nervous, tearful, or tense

Playing back their behavior to the student can be helpful in agreeing with them (and their parents) that they would benefit from referral to a school counselor .

The Student Referral to School Counselor form can be completed by the teacher or supervisor, captures their reasons for referral, and includes:

• Student and guardian name
• Behavioral reasons for referral
• Details of any incidents
• Actions taken to date
• Any risks that need to be captured

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The provision of remote healthcare or telehealth continues to grow in the fields of counseling and therapy (Kanatouri, 2020).

Powerful online platforms such as Quenza provide a wealth of ready-made tools, functionality, and templates for use with face-to-face or remote clients.

The article titled How to Build and Send Counseling Forms  explains how to use telehealth forms effectively and offers the following templates:

• Informed Consent for Online Counseling  defines what is expected and acceptable in online counseling.
• Patient Health Questionnaire  offers an online approach for assessing a client’s depressive symptoms.
• General Anxiety Disorder assessment is used to assess a client’s overall anxiety
• School Referral Form is useful for parents and teachers referring students for counseling
• Employee Counseling Form  captures employee information and details surrounding a potential incident along with corrective actions.

Each of the above forms and templates can quickly be built or modified for telehealth purposes with an online tool such as Quenza . The platform was built for practitioners by the PositivePsychology.com founders to meet the need for a user-friendly, engaging healthcare platform.

“The ultimate goal in process for many groups is to help group members respond to each other with a combination of therapeutic attending, and sharing their own reactions, and related experiences” (Cochran & Cochran, 2015, p. 329).

Group work can be underpinned by forms that act as interventions themselves or capture the work for evaluation during or after its performance.

Evaluating a group’s performance

Use the Support Group Evaluation Form to capture individual experiences of the group’s performance that will help structure counseling going forward.

For example:

What did you like most about the group? What did you like least about the group? How do you rate the group overall? (0 = had no value; 10 = incredibly valuable) How much of a difference has this group made to your life? (0 = none at all; 10 = a great deal) Did you feel safe raising points or asking questions? (0 = not at all; 10 = a great deal)

Parental consent for group counseling

Like individual counseling, parents’ consent must be sought to attend group sessions.

Use the Group Counseling Permission Form to get consent from parents before introducing a child to group counseling.

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We have many free resources, including forms for counseling, such as:

• BASIC-ID Template for Multi-Modal Coaching This helpful template uses multi-modal coaching to assess clients’ habits and how to break them.
• Session Feedback Form Capture your client’s evaluation of a session and use it to improve future counseling.
• Coaching Intake Form Complete this form before attending life coaching to help the counselor prepare for the first session.
• Brief Mental Status Exam Form Use this form to capture the results of a brief mental status exam .

More extensive versions of the following tools are available with a subscription to the Positive Psychology Toolkit© , but they are described briefly below:

• Backward Goal Planning

Planning and preparation are integral to goal achievement and a powerful intervention in counseling.

This form facilitates planning in reverse chronological order to minimize the likelihood of viewing the present reality as an obstacle to achieving the client’s desired end state.

• Step one – Identify and visualize the end goal.
• Step two – Identify and outline the steps to get there.
• Step three – Take action and reflect on the progress.
• The Energy Audit

Complete this audit form to help clients manage their energy throughout the day.

• Step one – Use the form to track energy levels.
• Step two – Plot daily energy levels.
• Step three – Use the form in the counseling session to discuss how to replenish energy levels.

If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

A collaborative working relationship is fundamental to a positive therapeutic alliance and should be embedded from the very outset of counseling (Nelson-Jones, 2014).

Creating, completing, and safely storing intake, assessment, referral, and other essential forms help ensure:

• A robust therapeutic alliance between counselor and client
• The client’s needs are put first
• Confidentiality is maintained, and appropriate records are kept
• Treatment is appropriate and working toward client goals

Appropriate form use encourages a complete understanding of the client’s circumstances, whether as an individual, part of a couple, an employee, or a student. The forms facilitate treatment by clarifying and communicating the counseling approach and the client’s expectations.

For the student, member of staff, or the couple, the forms record the changing dynamics, understandings, and situation and can be referenced to measure progress toward treatment goals.

The forms and templates in this article can be merged and modified as appropriate to the structure and theoretical approach adopted by the counselor. They provide feedback, learnings, and confidence for the growing professional, potentially marking avenues for future training and skill development.

For a HIPAA-compliant system that creates and stores all your forms electronically, and makes it easy to send them to clients for completion, consider Quenza,  built with the practitioner in mind.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• Anderson University. (n.d.). When to refer students to counseling services . Retrieved February 23, 2022, from https://anderson.edu/uploads/campus-life/refer-students-to-counseling-services.pdf
• Cochran, J. L., & Cochran, N. H. (2015). The heart of counseling: Counseling skills through therapeutic relationships . Routledge, Taylor & Francis Group.
• Corey, G. (2013). Theory and practice of counseling and psychotherapy . Cengage.
• Kanatouri, S. (2020). The digital coach . Routledge.
• Knox, R., & Cooper, M. (2015). The therapeutic relationship in counselling and psychotherapy . SAGE.
• Lagerveld, S., & Blonk, R. (2012). Work-focused psychotherapy can help employees return to work sooner . American Psychological Association. Retrieved February 23, 2022, from https://www.apa.org/news/press/releases/2012/02/psychotherapy
• Nelson-Jones, R. (2014). Practical counselling and helping skills . Sage.
• Sommers-Flanagan, J., & Sommers-Flanagan, R. (2015). Study guide for counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (2nd ed.). Wiley.
• Williams, M. (2012). Couples counseling: A step by step guide for therapists . Viale.

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Counselling Case Study

Counseling case study, i. introduction.

[Your Company Name] is pleased to present a counseling case study focused on the successful treatment of anxiety using Cognitive Behavioral Therapy ( CBT ). As a leading provider of mental health services, [Your Company Name] is committed to delivering evidence-based treatments to improve the well-being of our clients.

In this case study, we explore the journey of a client struggling with severe anxiety and the therapeutic interventions employed to facilitate recovery. [Client Name] , a 32-year-old woman, sought counseling at [Your Company Name] due to debilitating anxiety symptoms that were significantly impacting her daily life. She reported experiencing persistent worry, racing thoughts, difficulty concentrating, muscle tension, and frequent panic attacks.

[Client Name] expressed frustration and hopelessness, as her anxiety prevented her from engaging in social activities, pursuing career opportunities, and maintaining healthy relationships. Recognizing the severity of her symptoms, [Client Name] was motivated to seek professional help and was open to exploring different therapeutic approaches.

II. Background Information

A. client background.

Name: Samantha Smith

Gender: Female

Occupation: Marketing Manager

Presenting Concerns: Severe anxiety, panic attacks, avoidance behavior

History of Presenting Concerns: Symptoms have been present for the past 5 years, progressively worsening over time

Psychosocial History: Single, lives alone, strained relationship with family, limited social support network

Medical History: No significant medical issues were reported, no history of substance abuse

B. Assessment

Upon initial assessment, Samantha Smith scored high on measures of anxiety severity, including the Generalized Anxiety Disorder 7-item (GAD-7) scale and the Beck Anxiety Inventory (BAI). She exhibited symptoms consistent with Generalized Anxiety Disorder ( GAD ) and Panic Disorder.

Additionally, Samantha Smith displayed maladaptive cognitive patterns, such as catastrophic thinking and overestimation of threat, contributing to the maintenance of her anxiety symptoms. Collaboration with Samantha Smith revealed underlying beliefs related to perfectionism, fear of failure, and concerns about social evaluation.

III. Treatment Plan

A. goals of treatment.

Reduce Anxiety Symptoms: Decrease the frequency and intensity of panic attacks, and alleviate generalized anxiety symptoms.

Improve Coping Skills: Develop effective coping strategies to manage stress and reduce avoidance behavior.

Challenge Maladaptive Beliefs: Identify and challenge cognitive distortions contributing to anxiety.

Enhance Self-Efficacy: Increase confidence in handling challenging situations and building resilience.

B. Therapeutic Interventions

Cognitive Restructuring: Utilize cognitive restructuring techniques to challenge irrational beliefs and replace them with more adaptive thoughts. Employ cognitive-behavioral techniques such as examining evidence, identifying cognitive distortions, and reframing negative thoughts.

Exposure Therapy: Gradual exposure to feared situations to desensitize Samantha Smith to anxiety-provoking stimuli. Develop an exposure hierarchy to systematically confront feared objects or situations, starting from least to most anxiety-inducing.

Relaxation Techniques: Teach Samantha Smith relaxation techniques such as diaphragmatic breathing, progressive muscle relaxation, and mindfulness meditation to reduce physiological arousal and promote emotional regulation.

Behavioral Activation: Encourage engagement in pleasurable and meaningful activities to counteract avoidance behavior and increase positive reinforcement.

Homework Assignments: Assign homework exercises to reinforce therapeutic concepts learned in session and encourage generalization of skills to real-life situations.

IV. Progress and Outcome

Throughout 12 sessions, Samantha Smith demonstrated significant improvement in her anxiety symptoms and reported a reduction in the frequency and intensity of panic attacks. She exhibited enhanced coping skills and greater self-awareness of her maladaptive thinking patterns. Through cognitive restructuring exercises, Samantha Smith was able to challenge and reframe her negative beliefs, leading to a more balanced perspective on her experiences.

Gradual exposure to feared stimuli allowed Samantha Smith to confront her anxieties and build confidence in her ability to cope with discomfort. After treatment, Samantha Smith reported a marked improvement in her overall quality of life. She expressed feeling more empowered to face challenges and engage in activities that were previously avoided due to anxiety. Samantha Smith demonstrated resilience and a willingness to continue utilizing the skills learned in therapy to maintain her progress.

Follow-up assessments indicated sustained gains in symptom reduction and improved psychosocial functioning. The successful outcome of this case underscores the efficacy of CBT in treating anxiety disorders and highlights the importance of collaborative therapeutic work in facilitating recovery.

V. Conclusion

This counseling case study illustrates the effective application of Cognitive Behavioral Therapy in addressing severe anxiety symptoms. Through a combination of cognitive restructuring, exposure therapy, and skill-building exercises, Samantha Smith was able to overcome debilitating anxiety and regain control over her life.

The collaborative efforts between the client and therapist yielded positive outcomes and underscored the importance of evidence-based interventions in mental health treatment. [Your Company Name] remains committed to delivering high-quality counseling services that promote healing and well-being for individuals struggling with mental health concerns.

Prepared by:

Dr. [Your Name]

Contact Details:

[Your Company Email]

[Your Company Number]

[Your Company Name]

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Accreditation

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• What is CBT?
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Are you a member yet? Membership is open to all and is the first step towards accreditation.

• Case Study Marking Criteria
• Close Supervision Guidelines
• Cognitive Behavioural Psychotherapist Accreditation FAQs
• Core Professions
• Knowledge Skills and Attitudes

Guidance for assessing case studies

The BABCP Minimum Training standards require that at least four training cases must be presented and formally assessed as case studies. Case studies must meet our standards for formal assessment listed below.

The BABCP case study marking criteria (formerly known as Criteria for Evaluating Academic Case studies 2013) can be downloaded here .

Case studies are normally assessed as part of post-graduate CBT training. However, not all courses include all four we require. If this applies to you, or you do not have evidence of all the passed case studies, this document provides guidance on both how to write and assess case studies marked independently for accreditation. 

Details of Training Cases

The criteria for BABCP CBT Practitioner Accreditation are set out in our Minimum Training Standards (MTS 2021) - 

• at least four of the eight training cases must be presented and formally assessed as case studies, a further three must have received close supervision
• written case studies should be between 2000-4000 words (or 3-5000 if extended).
• the case studies can cover the same cases that are closely supervised or they can be different
• two of your formally assessed case studies may be delivered as a ‘live’ case report or presentation instead of a written study – if so, there should be supporting information such as slides or a written summary as part of the formal assessment
• case studies must be marked as a ‘pass’ 
• the marker must have experience of marking CBT case studies in an academic setting
• the completed mark sheet for the case study should be submitted along with an application for accreditation

A Suitable Assessor

The assessor should be accredited by BABCP or be a CBT therapist who is trained and qualified in CBT to postgraduate diploma level or equivalent (or would meet Minimum Training Standards ). 

In addition, they should have experience of marking as a lecturer or tutor on an academic post-graduate CBT training course or equivalent. The assessor may, however, currently be independent of an academic institution.

If possible, we recommend that you contact assessors from your course, local courses or through other contacts. Otherwise, you can download a list of independent assessors  here .  It will be your responsibility to check that they still meet the criteria for a suitable assessor and to negotiate fees, timescale and, if appropriate, reasonable adjustments with them.

Assessors are asked to confirm that the case study has passed– this means that it is of an acceptable standard for a competent CBT therapist. Feedback should be given to the candidate and expectations of quality, content, layout, writing style and structure should be of a similar standard as case studies marked in a post-graduate programme.

Reasonable adjustments should be made where appropriate where the applicant can provide evidence of relevant additional needs.

The case study should demonstrate theoretical understanding and a research-based rationale for choosing a specific approach and knowledge of alternative options, which is consistent with evidence-based CBT practice. There should be a reflective element which identifies new learning.

All the areas described below should be covered where relevant.

Evidence of structured assessment, including the following areas -

• risk assessment
• current circumstances
• details of current presenting problem(s) and/or diagnosis, including co-morbidity and reason for seeking treatment at this point
• relevant personal history including development of the problem, previous treatment(s) and current coping
• use of appropriate standardised psychometric and idiographic measures
• suitability for CBT and socialisation to the model
• identified treatment goals
• assessment of diversity and relevant socio-cultural factors

Literature Review

• detailed description, explanation and critical evaluation of relevant CBT model(s) with rationale for choice of model
• knowledge of evidence base underpinning the theoretical model and chosen intervention(s)
• any adaptations to the model needed for the case

Case Formulation

The report should outline a coherent, concise formulation developed collaboratively over treatment with explicit input from client and include- 

• evidence of individualised formulation at maintenance or cross-sectional level in keeping with diagnosis specific or generic CBT model, which is appropriate to the presentation and justified by the evidence base
• explanation of links between elements in maintenance cycle
• diagrams of maintenance cycles (and longitudinal formulation, if appropriate)
• identification of a trigger or critical incident/explanation of onset of problems (precipitating factors)
• underlying beliefs/assumptions (predisposing cognitive vulnerability factors) and explanation of links between these and maintenance cycles
• explanation of how past events may have contributed to/reinforced the beliefs
• awareness of any missing elements

Course of Therapy and Outcome

• Identification of theoretical aims of treatment according to the model used, and in relation to client’s presenting difficulties and goals for treatment
• treatment plan explicitly linked to formulation
• clear identification and description of the main phases of treatment and detail on at least two specific change processes, including the cognitive and/or behavioural interventions utilised and the rationale for their use
• examples of written materials used (may be in appendices)
• justification of any deviation from model or protocol used
• identification of client’s learning
• continued refinement of formulation (if necessary)
• evaluation of outcome including progress towards treatment goals
• changes in psychometric and idiographic measures, changes to client’s general functioning and client’s evaluation of therapy relapse prevention plan
• reflection on the progress of therapy and outcome of therapy, and the therapist’s learning. Including identification of therapist and client factors that helped or hindered therapy, use of supervision, the role of the therapeutic relationship and likelihood of treatment gains being maintained 
• comment on the therapeutic alliance (interpersonal process) and if relevant how difficulties in treatment or the therapeutic relationship are understood in terms of the formulation, and how these were managed
• identification of what therapist may have done differently given another chance
• broader implications for the model or evidence base
• reflection on diversity and relevant socio-cultural factors

Structure, Presentation, References

The overall presentation should include -

• coherent structure with logical flow 
• clarity of communication, grammar and spelling
• use of diagrams, tables and/or figures where appropriate
• quality of referencing in text and in reference list
• limited, judicious use of appendices 

Additional guidance for verbally presented case studies

The criteria for written case reports above should be applied to marking verbally presented case studies, including the assessor criteria and the requirement for the report to pass. In addition -

• the presentation should include the opportunity for assessor(s) to give feedback and ask questions
• the presentation should be a minimum of 30 minutes’ duration (which may include the time for questions)
• there should be supporting information such as slides or a written summary
• any marking criteria that relate to the written aspect of the presentation should be used to assess the verbal aspect of a verbally presented report e.g. adhering to the word count would be equivalent to adhering to the allocated time
• as with written reports, the presentation should meet the standards expected of a healthcare profession with a post-graduate level qualification e.g. accurate and detailed slides, clarity of expression, logical sequence covering the areas outlined above, clarity and coherence of the content, respect for client confidentiality, effective use of tables and figures, lack of grammatical and spelling errors, appropriate links to evidence base and referencing 

Marking and Feedback

A BABCP case study feedback sheet is available here . It is optional and assessors can use a different system of ensuring and demonstrating that the case studies have met all of the requirements. 

A copy of the feedback sheet should be sent to the applicant for them to include with their accreditation application.

If the case study is not marked as a pass, please provide the applicant with constructive feedback. 

We may request a copy of the report in order to moderate the marking. 

Clinical Case Study

Ai generator.

In 1970, the world first got acquainted with Genie. It was also the little girl’s first time to see a world beyond the potty chair where she was often bound to. Barely a contact outside for most of her life, she was a ripe case for studying the effects of extreme isolation in young children. Clinical case studies shed light on rare and specific circumstances, like Genie’s ordeal, that help us understand the bigger picture. Largely qualitative research , these case studies are an attempt to understand a subject and the case, usually in relation to a general concept.

8+ Clinical Case Study Templates and Examples

Clinical case studies can focus on a person, group, or community. In contrast to case reports , these studies don’t end in reporting about the diagnosis, treatment, and follow-up of patients. Case studies abide by the research methodology and design to understand an experience. During a case study analysis, both subjective and objective accounts of the events are deemed valid data. By focusing on a pixel of the picture, you can learn something that you would have otherwise overlooked. We have prepared the following case study templates that you can use in your research. For your reference, we added examples of scenarios where clinical case studies are being used.

1. Case Study Analysis Template

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Size: A4 & US Letter Sizes

Case studies are a common method of research in medical and psychological sciences. They are vivid narratives about undocumented cases that strike researchers as irregular and interesting. Their highly descriptive content are valuable information to the respective scientific community. They also open new avenues of inquiry and offer an in-depth treatment of a topic that empirical research cannot give. Its comprehensive nature helps make case study a popular research option, even if it falls short of evidence-based data. Thinking of using this research method? Get started with this template!

2. Clinical Case Study Template

Size: 49 KB

Since the studies contain detailed accounts, you have to format all the information into categories. The defined structure of the article makes all the information easy to absorb. A case study generally contains the following sections: abstract, introduction, patient information, review of related literature, methodology , findings, then the conclusion. The comprehensive nature of this research method might deter novice researchers, while veteran medical writers might just need a reminder. In either case, this sample outline is for you!

3. Clinical Case Study Sample

Size: 939 KB

This research method is usable in answering different inquiries. It is notable that case studies are heavy on the qualitative data. Researchers can obtain relevant data from interviews, questionnaires , personal and patients’ observations, journals, clinical reports, and existing literature. However, as seen in this attached example, quantitative data can also be collected as the researchers deem fit. Because the goal is not to derive data that can represent a population, researchers can use a smaller sample size. Study how to make both numbers and descriptions work to your advantage in preparing your clinical case study with this example!

4. Medical Case Study Example

Size: 563 KB

In a physician’s life, he or she is bound to come across a case that medical school and textbooks did not warn him or her. Clinical case studies are a form of communication about novel findings or observations in practice. Sort of like a medical buzz, the studies contain information like unreported health complications, adverse response to treatment, or new remedial methods. These case studies can also branch into new research directions. This case study illustrates how misdiagnosis can be harmful to the patient. Because some diseases can have overlapping symptoms, it can be hard to identify which is which. The case study alerted the medical community that a seemingly mundane skin condition can point to something more serious.

5. Psychological Case Study Example

Size: 425 KB

In the field of psychology, clinic psychologists and therapists can report about their interactions with the patient. Some of these cases can stand out as rare and unusual. Others may also serve as a useful reference. Practitioners can obtain information through semi-structured interviews wherein the patient talks with a mental health professional. After the sessions, the practitioner can interpret his or her findings into diagnosis and recommend a treatment plan . Psychology is not entirely removed from medicine. The specialist can incorporate the medical history of the patient in his or her interpretation. This sample case study shows medicine and psychology can work together in the prevention of stress-induced asthma attacks.

6. Sample Clinical Case Study

Size: 85 KB

The descriptive take of clinical case studies on a situation presents an exhaustive analysis that is not available in empirical research. However, the qualitative nature of these studies is a double-edged sword. The combination of subjective and objective analysis makes the content susceptible to personal biases. Because the case is unique to an individual or a group, researchers cannot replicate the result. The replicability of findings is a hallmark of reliable research. Therefore, clinical case studies have a low-reliability measure. The attached case study is an example of the use of descriptive analysis in the diagnosis and treatment of a patient with depression and adjustment disorder with mixed anxiety.

7. Medical Case Study Guide

Size: 266 KB

Another point raised against clinical case studies is the issue of memory distortion. The human memory is not a machine that can record and retrieve information at command. It is fallible, and it will make mistakes. The patients can emphasize a few parts of their history and overlook otherwise important pieces of the puzzle. Reliance on memory recall when writing the study can also fail the researchers. The sample clinical case study added here shows how a patient’s recollection of events in her life can be used in the presentation of the case. If the patient failed to recall important details, the researchers might have a different interpretations of the case.

8. Student Medical Case Study

Despite criticisms regarding susceptibility to biases and low-reliability measure, clinical case studies have been an indispensable tool for learning. Studies have reported a significant improvement in the academic performance of students after the integration of case studies into the learning ecosystem. Case studies are situation-based narratives about a textbook principle. Application-motivated learning is effective because the theoretical framework isn’t removed from the real-world experience. This case study is an example of those that are used in the classroom. The students are presented with a problem and series of follow up questions that will help them understand and address the issues exhibited.

9. Clinical Case Study Article

Size: 171 KB

Unlike empirical investigations, the goal is not to come up with results that can represent a population. Case studies focus on understanding an unusual plight through subjective and objective analysis. Understandably, such situation might not hold for most people. They are also the method of choice for understanding circumstances that cannot be reproduced in controlled testing environments, like Genie’s case earlier or the case discussed in the attached case study sample. Therapy for anorexia nervosa and obsessive personality disorder is hard to come by using quantitative research. Replicating such conditions will constitute a criminal offense. What case studies lack in the universality of the results, they make up for the richness of the insights obtained. It acknowledges that the human experience will always have a degree of subjectivity. This defense of clinical case studies makes them significant in their own right.

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