Follow This Format And Deliver an Awesome Case Presentation!
Case presentations can be frightening. Your clinical reputation is on the line with gut-check questions running through your mind. Did I remember everything? What if my interventions are wrong? Can they tell I’m nervous? What will my colleagues think? What if my professor thinks I’m an idiot?
Don’t worry. You are not an idiot and the following format for presenting a case will amaze your colleagues, impress your teachers, and cement your reputation as an outstanding up-and-coming therapist.
Does this sound too good to be true? It’s not.
The following format is simple and comprehensive; most importantly, it works.
The format consists of 11 sections: demographics, presenting problem, goal, legal/ethical, crisis/safety, diversity, assessment, provisional diagnosis, treatment plan, interventions and the beginning, middle and late stages of treatment.
It seems like a lot of information, but a succinct presentation takes about 20-30 minutes. Your deserved applause will take up another 10 minutes.
Demographics are the facts, the nuts and bolts about the client. Demographics include the client’s name, age, gender, relationship status, ethnicity, occupation, length of employment, age and gender of any children.
Example: Mary T. is a 25 year old married bi-racial female who has worked for City Savings and Loan as a teller for the last 2 years. She has been married to her husband for 4 years. They have no children and no previous marriages.
The presenting problem is the reason why the person is receiving your services. The presenting problem can also be called the client’s chief complaint.
Example: Mary presents with multiple concerns related to an unfulfilling marriage, potential loss of employment, and concerns over her husband’s gambling.
Clients come to therapists to accomplish something. I think it is a good idea to find out what the client’s goal is. What do they want to get out of their therapy?
Example: Mary would like to first focus on concerns related to her husband’s gambling. Mary states that her husband told her last week that he is approximately $45,000 in debt. Mary is also worried about her job security.
This is a one of the most critical categories. Not addressing your legal and ethical responsibilities can be a show stopper. For your career, I mean.
Make sure you know what your legal and ethical responsibilities are at all times. If you have any questions, please ask your supervisor or someone licensed in your field of study.
Generally, your legal and ethical responsibilities include:
- You must indicate your status as an intern, if this is the case.
- You must provide the name of your supervisor.
- You must provide a written Informed Consent that usually includes information about the limits of confidentiality, your responsibilities in reporting abuse, your fee, your cancellation policies, and what the client should do if an after-hours clinical emergency happens.
- Provide proper HIPAA notification, if you or your office is considered a “covered entity.”
- If seeing a couple, it is always a good idea to discuss your “secrets” policy.
Example: Mary signed the Informed Consent. She was notified of my status as an intern and the name of my supervisor. She was verbally informed of the limits of confidentiality, cancellation policy, and office fees. Mary signed the Acknowledgment of HIPAA Guidelines form.
Is the client in crisis? If so, describe the type and severity of the crisis and your interventions to address this concern. You must be exact.
Example: While her situation is difficult, Mary does not appear to be in crisis at this time. She denied any thoughts or feelings related to self harm. She denied any past history of self harm. There are no reporting responsibilities present. She seems to have an active and extended support system.
What are the differences between you and the client? These differences can be about age, gender, education, socioeconomic status, sexual orientation, marital status, religion, stage of life, and should be noted.
The concern is whether or not these differences pose a difficulty for the therapist to remain objective and focused on the client’s concerns. If the differences between the client and therapist are too great for the therapist, it should be noted how the therapist will handle this problem.
Example: There are some differences between Mary and myself. While we are of the same gender, she is married and I am not. Mary is of a different ethnicity than I am and she is a few years younger than I. There may also be some differences in our educational background, as well. I do not feel these differences will impede our working together. If I felt otherwise I would discuss my concerns with Mary to see if she had any similar concerns. Secondarily, I would seek consultation from my supervisor or a clinician skilled in working with someone from her culture. If the differences between us were too great and I was not of optimal service to my client, I would provide her with an appropriate referral.
It is a good idea to state that despite the differences between you and the client you feel confident you can be of service. If the differences were too great you should discuss your limitations with your supervisor and get consultation from a clinician of more similar backgrounds. Or you can refer the client to a therapist with more similar demographics to the client than you have.
Your assessment is your impression of the client based on the assessment questions you asked.
For a good list of assessment questions click Assessment Questions.
Example: Mary is devoted to her husband and family, but is clearly struggling with their financial difficulties. She complains about increased anxiety, decreased sleep and some disruption in concentration. She notes a change in mood as she is “worried all the time” and finds herself crying when she feels hopeless. Mary does not describe herself as a person who worries a lot. Her acute symptoms seem particular to her husband disclosing the extent of his debts. She states her appetite is stable and has not experienced any recent gain or loss of weight. She is oriented to person, place and time. Thinking is linear and her memory appears good. Affect matches content. She states her performance at work is affected by her personal worries, but there is no current disciplinary action against her. She denies any suicidal or homicidal ideations or actions in the past or present. She states a social use of alcohol. She apparently has a strong support system which includes a large extended family and strong ties to her church community. She states her husband is generally supportive, they are effective parents, but has been less available due to his own worries. He has been avoiding her.
Here is where you get to show how smart you are! A good provisional diagnosis shows an ability to glean relevant information from your assessment and apply that information toward the possibility of different diagnosis.
A provisional diagnosis is a starting place. It is not meant as the final descriptor of the client. As you know, a diagnosis can change as symptoms change.
You are not expected to hit a home run with every provisional diagnosis, but you are expected to describe the client’s symptoms as they are ruled in or ruled out given a relevant potential diagnosis. You also must be able to prioritize their problems (usually based on what problem or situation is causing the greatest symptoms or concern).
Example: In considering Mary’s case, I am aware that her greatest stressor is stated as related to her husband’s gambling. Mary relates her changes in mood and concentration as directly related to worrying about their finances. Her predominant mood is described as anxiety, but Mary also complains about crying and feeling hopeless. She has been experiencing problematic symptoms for one week, thus ruling out a chronic problem.
Given this information I am leaning toward a provisional diagnosis of Axis I 309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood.
Due to the short duration of Mary’s symptoms and her statement that she is not typically a “worrier” I am ruling out Generalized Anxiety Disorder (GAD). Symptomatically she does meet some of the diagnostic criteria for this disorder namely, difficulty concentrating and disrupted sleep. However, GAD is ruled out as she does not meet enough symptoms, or for the required six-month minimum duration.
Mary states she cries often, feels hopeless at times, that her concentration is disrupted, and she has some difficulty sleeping. I am ruling out Major Depression, Single Episode as Mary’s symptoms are not inclusive, severe or long enough in duration to meet this diagnosis. Mary would need to show five of the required symptoms for a minimum of two weeks.
Therefore, given this clinical presentation my provisional multiaxial diagnosis is as follows:
- Axis I - 309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood
- Axis II - V71.09 No Diagnosis on Axis II
- Axis III - No medical conditions stated
- Axis IV – Economic Problems
- Axis V – GAF 70
At this point, the case presentation has given a description of the patient, why they have come to therapy, what their goal is, the outstanding legal and ethical concerns, any problematic differences between the therapist and client, the therapist’s assessment of the client and a provisional diagnosis.
The next step is to describe the therapist’s plan to address the problems noted by the client or therapist.
As you will come to see, clients often come in with multiple problems and may be dually or triply diagnosed. Therefore, how do you know which problem to address first? The correct order is:
- Issues of safety
- Any issue that requires reporting
- Any non-lethal or non reporting crisis
- The problem(s) generating the greatest symptoms
Given this case example the primary focus will be on the client’s anxiety, financial concerns, occupational concerns and problems with her husband.
The treatment plan might look something like this:
- Decrease client’s anxiety.
- Increase sleep and concentration.
- Provide referrals for financial resources and education.
- Improve communication and marital relationship with her husband.
Now that you have a plan laid out what interventions will address the client’s goals and reduce her problematic symptoms?
If you are presenting your case well into the treatment process, or after the case is closed, state the interventions completed and their result.
(Hint: You can look up interventions in various treatment planners, if you are not sure what to do. Click here to find a website where you can purchase a treatment planner for any kind of counseling service. Double hint: Strengthen your presentation by stating your theoretical orientation and why it is the best approach for these types of problems.)
Goal 1: Decrease client’s anxiety.
- Use Solution Focused Brief Therapy to focus on client’s strengths, skills and abilities in handling past crisis.
- Reinforce client’s current coping skills.
- Use a Cognitive Behavioral model to provide psychoeducation on the connection between thoughts, feelings and behaviors.
- Establish a Thought Record to identify distorted, irrational thoughts and reframe and identify more accurate, adaptive replacement thoughts.
- Identify anxiety triggers and coping strategies.
- Utilize activity scheduling to break problems down into manageable pieces and develop behavior plans to address each problem area.
- Schedule self care.
- Bibliotherapy: “Mind Over Mood” by David Burns.
Goal 2: Increase sleep and concentration.
- Refer to MD for assessment of sleep problem and possible short term sleep medication.
- Teach client diaphragmatic breathing to decrease anxiety and help as a sleep aid.
Goal 3: Provide referrals for financial resources/education.
- Refer client to Consumer Credit Counseling for low cost financial education, budgeting and financial planning services.
Goal 4: Improve communication and marital relationship with her husband.
- Refer client for couple’s counseling through client’s insurance.
- Provide client with information from CA Office of Problem Gambling as a resource for education and treatment options for problematic gambling. It is noted there are few resources targeting those affected by another persons gambling similar to Al-Anon for those affected by another persons substance abuse.
Stages of Treatment
Any course of treatment, and every session, has a beginning, a middle and an end.
The purpose of this section is to provide a brief outline of the treatment concerns and goals of each stage.
The following format is designed for approaches utilizing a longer course of treatment unlike some short-term approaches that do not assume a second appointment.
Beginning. As stated above, any issue of safety or crisis must be addressed first. If there is no crisis, then the beginning stage should include:
- conducting an assessment
- establishing goals
- addressing any legal or ethical concerns
- the business practices of fees, Informed Consent, cancellations, etc.
The beginning stage describes the interventions conducted to provide relief for the client’s presenting problems.
Example: While Mary was clearly upset upon learning of her husband’s gambling problems she was not in danger. Her problem was acute, but not a crisis. After establishing goals, I used the Solution-Focused technique of exploring Mary’s strengths and abilities in handling past crises in her life. I focused on complimenting and reinforcing Mary’s current coping skills. I utilized a zero to ten rating scale for Mary to indicate the highest level of her anxiety and lowest levels of anxiety given her present concerns. I then asked her to identify what she is thinking and doing when her anxiety level is at its lowest. Knowing that Cognitive Behavioral therapy has shown to have a good treatment outcome for problems of anxiety I provided Mary with psychoeducation on the relationship between thoughts, feelings and behavior. By the second session I introduced a Thought Record for Mary to identify distorted, irrational thoughts and learn to replace these thoughts with more adaptive, productive thoughts. I provided Mary a Xerox copy of a Thought Record and Mary was instructed to use her Thought Record every day until our next appointment. Mary was referred to her MD to assess the value of short term sleep medication.
Middle. After any crisis has been ameliorated and the client is stable, we move into the middle stage of treatment. This is where the bulk of the work will be done.
If you are presenting this case before you have reached this stage, describe your interventions based on what you will hope to do.
Example: By the third session Mary reported a drop in her anxiety level. I asked her to again scale her highest level of anxiety since our sessions started and her current level of anxiety. We continued to work with her Thought Record to discover and reinforce thoughts based in her current reality helping her create confidence to handle her current situation. I introduced diaphragmatic breathing as a stress management technique practicing this technique in-session. Mary was provided the phone number and address to Community Counseling Center, a community based program to help provide low-cost financial education, budgeting and planning. Mary was encouraged to contact her human resources department to see if her company allowed emergency withdrawals from her retirement plans. As financial planning is out of my scope of practice, I encouraged Mary to discuss this with a qualified financial professional. Additionally, I developed an Activity Planning schedule to help Mary organize her time, manage her anxiety, build structure and set realistic, achievable goals. Mary was explicitly encouraged to make sure she schedules time to obtain support and focus on self-care activities. As Mary’s anxiety and sleep problems lessened we began to discuss her communication concerns with her husband. Mary was referred to a therapist within my agency and she and her husband did start couples therapy. I obtained the needed releases to coordinate care with the other therapist.
Late. The final stage of therapy involves solidifying the gains made, dealing with the issues of termination and providing any needed referrals. It is your ethical responsibility to provide next steps for the client upon ending your work together.
Example: By our eighth session, the symptoms Mary had presented upon intake were significantly lessened. She was utilizing resources from her MD to help improve her sleep. She was practicing diaphragmatic breathing to manage her physical symptoms of anxiety. She was using her Thought Record to actively replace thoughts that created anxiety with more realistic coping thoughts to strengthen her confidence. Mary and her husband had received useful advice from Consumer Credit Counseling and had worked out a realistic payment schedule to manage their debt. Reluctantly, Mary had even scheduled time for self care. Given her gains made I began to introduce the idea of termination as Mary had made significant progress in achieving her goals. We agreed to decrease the frequency of her sessions to twice a month. At the tenth session we agreed that barring any changes our next session would be our last. At our final session Mary’s rated level of anxiety was well below her initial visit. She stated feeling more confident in her abilities to handle her worries and that, in the long run, things will work out. Mary stated that she was planning to continue in couples therapy with her husband. She was appreciative that he was willing to work on their relationship. Mary was told she could always call back if she needed further assistance.
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