case study

Personal Background and Client Referrals

  • When conducting a case study, begin with an introduction that includes:

    • Client's personal background
    • Relevant demographic information
    • General identity
    • Behavioral observations

  • Factors to consider regarding the client’s background include:

    • Demographics
      • Example: Age, gender identity, and ethnicity.
    • Identity
      • Example: How they identify themselves socially and culturally.
    • General appearance
      • Example: Clothing style, grooming, posture.
    • Behavioral observations
      • Example: Physical posture, fidgeting (e.g., client's leg shaking in class).

  • Specific considerations during observations:

    • Mood: What is the client's prevailing mood?
    • Affect: Is their affect flat or animated?
    • Speech: Determine if they are hyperverbal or exhibit limited verbal communication.

  • Context of the referral:

    • Identify the referral source (e.g., principal, school psychologist, or parent).
    • Clarify that this section only names the referral source without providing a detailed reason for the referral.

Pseudonyms and Client Confidentiality

  • Use of pseudonyms is encouraged to maintain client confidentiality:
    • For your own assignment, create a pseudonym to refer to the client throughout your case study.
    • Example: Choose names like "Jessica" or a more generalized description (e.g., "graduate student in Northern California").
  • Avoid detailed identifiers that could reveal the client’s identity (e.g., specifying the university could be too identifiable).
  • Maintaining confidentiality includes:
    • Always stating clearly that the name used is a pseudonym.
    • Not including overly specific details such as exact locations or identifying features.

Structure of the Case Study Assignment

  • The case study must not follow a grid format; instead, it should be a narrative.
  • Sections to include in the case study:
    • Personal Background
      • Introduce the client with a brief paragraph detailing demographics, identity, and physical observations.
    • Presenting Problem
      • Discuss the major issue the client is facing. For example, "Client reports struggling with low motivation and difficulty in implementing self-care routines."
    • Treatment History
      • Briefly describe previous treatments or mention if this is the client's first attempt at therapy.
    • Family/Social History
      • Include relevant family background information that may impact the client's presenting problem.
    • Goals and Interventions
      • Clearly outline three client goals and corresponding therapist interventions.

Formatting Requirements

  • Formatting for the case study:
    • Use 1.5 line spacing and Times New Roman font.
    • Set margins to one inch on all sides.
  • Length requirements for sections may vary:
    • Presenting Problem: Approximately three-quarters of a page.
    • Other sections (treatment history, family/socio-historical context) may not have set lengths but need to be concise and clear.

Detailing Behavioral Observations

  • Important to convey the client’s behaviors and demeanor during the first session:
    • Examples of behaviors to note:
      • Physical stance (e.g., sitting posture, eye contact)
      • Emotional cues (e.g., expressions of sadness or anxiety)
      • General demeanor (e.g., engaging vs. withdrawn).
  • For example:
    • Client may enter wearing disheveled clothing and avoiding eye contact, indicating social withdrawal or discomfort.

Clinical Terminology and Documentation

  • When describing client behavior, utilize clinical terms:
    • For example, you might describe their speech as "normal speech rate" or "pressured speech."
  • Include pertinent mental status exam notes such as:
    • Client is oriented to time, place, and purpose (known as being oriented times four).
    • Document if client exhibits no hallucinations or delusions.
    • State the absence of suicidal ideation when applicable.

Goals and Therapist Interventions

  • Goals outline what the client aims to achieve:
    • Example: Increase self-care practices, improve motivation for day-to-day activities.
  • Interventions are specific actions the therapist will take to facilitate goal achievement:
    • Example: "The therapist will teach relaxation techniques and encourage the client to practice them regularly."
  • Maintain a clear distinction between goals (client responsibility) and interventions (therapist actions).