Appendix B: Case Study Guidelines
General Guidelines
- Disguise all case material.
- All Case Study papers should be written using a current client in your practicum learning internship.
- Write no more than 25 double-spaced pages.
- Support statements with citations from the literature.
- Illustrate points related to assessment, treatment goals, interventions and/or treatment processes by embedding segments of the appended process recording (or other process recordings related to the case).
- Citation sources are to be listed in a "References" section at the end of the paper.
- Papers should be prepared and formatted according to APA guidelines (See Publication Manual of the American Psychological Association, 7th Edition) and the "Case Study Guidelines" provided here.
Case Study Face Sheet (use a current client from your practicum learning internship)
To be used as the first page of case study papers, the Face Sheet summarizes sociocultural information for both you and the client.
Introduction
State the purpose of your paper, including the particular psychological theory you are using. Note that 'client' can refer to an individual, couple, or family, but for purposes of applying these theories an individual client is the best choice.
Demographics
Client's self-identification and description of gender, age, socioeconomic status, race, ethnicity, faith-based affiliation, sexual orientation, ability/disability, primary language, history of geographic location, marital/relational status, level of education, current occupation, living situation, and family context. Note relevant attitudes and experiences regarding these factors and awareness or lack thereof regarding privilege.
Referral Information
Briefly describe agency, services available, and clients served. Note whether referral is voluntary. Provide the views of presenting issues as expressed by both the client and clinician. Describe the client's mental status, physical appearance, and style of relating. Note current and prior contact with mental/behavioral health, social service, and/or legal systems.
Biopsychosocial-Spiritual Assessment
Describe the strengths and vulnerabilities in each of the following areas and provide a summary at the end of the review:
- Biological. Previous and current history of mental and physical health concerns, including: illnesses; hospitalizations; medications; substance use and abuse; nutrition; physical, sexual, emotional and cultural/racial trauma; and genetic predisposition toward learning disabilities and other health challenges.
- Psychological.
- Developmental accomplishments and ruptures throughout life cycle including significant losses;
- Family of origin and extended family systems, including separations, divorces, foster care, adoption history, incarcerations, parole/probation, other significant events and relationships.
- Create a genogram.
- Social/cultural. Current living arrangement, work/school situation, and support networks (e.g. family, friends, co-workers, neighbors, faith-based communities)
- Spiritual.
- Cultural orientation toward spiritual and faith-based practices;
- World views and values
DSM Diagnosis
Note the diagnosis that best describes the client, or other diagnoses that you would have considered. Comment on level of functioning.
Theoretically-Grounded Conceptualization
Demonstrate your ability to conceptualize the strengths and vulnerabilities in assessment, treatment planning and treatment processes within one theoretical paradigm. Address how the client's history affects his or her presenting issues. Use the developmental constructs relevant to the psychological theory you are using.
Treatment Plan (agency-based and theoretically-grounded articulation of goals, interventions & evaluation)
Demonstrate your ability to use your biopsychosocial-spiritual and theoretically grounded assessment to craft the development of a treatment plan. Articulate treatment goals and interventions both in Agency-based language as well as within your one chosen theoretical paradigm. Support your statements with citations from the literature and include a list of these references at the end of the paper. Describe the course of treatment as it relates to your theoretical understanding. The following points should be addressed:
- Short- and long-term goals. Describe both your client's and your own view of goals and how you arrived at agreed upon goals. Describe short-and long-term goals in agency-based language and in the language of one chosen theory. Write a brief summary of the goals in the text and include the goals and Interventions in an outline form. Note how you changed or re-focused goals, especially if the treatment is long-term.
- Interventions. Note types of interventions, once again in Agency-based language as well as the language of your chosen theory. Describe these interventions in the text and include the interventions that are aligned with specific short and long-term goals in an outline form. Interventions may include strategies and methods used by the clinician including techniques employed during clinical sessions and interventions at the home of the client as well.
- Transference/Countertransference. Discuss the current functioning and ways of relating that your client displays. Describe transferential and countertransferential themes and dynamics played out through projective identification. Discuss your understanding of these themes through the one theoretical perspective that you have chosen.
- Impasses. Discuss any impasses or ethical dilemmas raised by the case. Evaluation of practice. Write a brief, cogent synopsis of your assessment and conceptualization of the case. Demonstrate the evaluation of practice, in both Agency based and theoretical languages, by addressing how effectively the short and long term goals were realized during the course of treatment.
Consultation Questions
Identify two or three concerns or questions about your case that you would like a consultant to address.
Process Recordings
Provide 2-4 pages of verbatim process recordings that involve the actual dialogue between you and your client during various clinical encounters and sessions (i.e. I said, She said).