Ph.D. Case Summary

Guidelines

Important Note: If accepted, the case material you provide will be used in your first year practice class.

No more than 10 double-spaced pages. Disguise all case material. Support statements with clinical data and citations from the literature. Prepare paper according to APA guidelines and the Case Study Guidelines below.

  1. Identifying Information
    Client's age, gender, race, ethnicity, religion, marital status, employment, resources (family, friends, etc.), and immigration status.
    Describe client's appearance and intelligence. Include client's reactions to the social worker.
  2. Referral Sources
    Who referred the client? Why? Is treatment voluntary or involuntary? Does the client understand the reason for referral?
  3. Presenting Problem
    How does the client see the problem? Why has he/she come?
  4. History of the Problem
    How did the problem develop? Is it chronic or acute? Describe precipitating events and the course of the problem. Under what circumstance is the problem manifested (home, school, work)?
  5. Previous Counseling Experience
    Discuss any previous treatment/counseling. What do you know about the treatment and its outcome? What do you know about the previous therapeutic relationship?
  6. Family Background
    Discuss socioeconomic, educational, and occupational background of the family. How do family members interact? Include a genogram.
  7. Personal History
    If client is a child, include a developmental history (i.e., toilet training, language, motor development).
    If client is a child or adult, discuss any developmental interferences. Include information about process, levels of achievement, learning differences. How did the client cope previously?
    Include a vocational history (adaptation to jobs, bosses, co-workers, recreational activities).
    Is there a past use of substances?
    Include a sexual history as well as any past or current physical, sexual, or emotional trauma.
  8. Medical History
    Discuss any illnesses or organic factors that may contribute to psychosocial difficulties.
  9. Education
    Discuss any diagnosed or undiagnosed learning differences (i.e., processing problems, dyslexia, ADHD, Aspergers). If client is a child, summarize educational evaluations.
  10. Social Class
    Consider socioeconomic history, including social class changes. If a couple, discuss social class differences. Discuss if client is of higher or lower socioeconomic class than therapist.
  11. Cultural Context
    Discuss current problem within its cultural context. Address history of immigration, languages spoken, interactions with cultural institutions, traumatic stressors, crises, health beliefs, family, education, and work values.
  12. Spirituality/Religion
    Discuss current or past spiritual or religious affiliations. How do these factors contribute to understanding the client's perception of life events? How might they affect the treatment?
  13. Mental Status
    Discuss client's current functioning. Use an ego psychological framework to discuss client's ego functions, defenses, strengths, limitations (social, psychological, physical, or environmental).
    Evaluate the client's motivation, degree of self-awareness, capacity for insight, and ability to follow through with treatment.
    Comment on client's appearance, attitude, motor activity, affect and mood, speech, thought processes, thought content, perception, orientation, judgment, and capacity for abstraction.
  14. DSM V Diagnosis
  15. Conceptual Understanding
    Using all the data presented, how do you conceptualize this case theoretically? What theory or theories (i.e., drive, ego psychology, object relations, self psychology) inform your assessment and practice? Draw upon the theoretical constructs that help you understand the client's story. Discuss how the theory helps you understand the problem and how the theory informs the
    treatment.
  16. Recommendations for Treatment
    Based on your theoretical formulation, discuss treatment recommendations, including the client's reactions to them, other recommendations perhaps not provided by your agency, duration and frequency of treatment, and any potential problems in treatment.
  17. Therapeutic Relationship
    In light of your conceptualization and goals, discuss the therapeutic relationship, including impasses in the treatment, transference/countertransference, and ethical dilemmas.
  18. Treatment Evaluation
    In light of treatment goals, evaluate the treatment to date. Consider the factors that have facilitated or impeded therapeutic progress. To demonstrate growth or lack of progress, discuss the goals and objectives of client and therapist in light of the actual practice. Consider what variables may be impeding or facilitating the therapeutic process.
  19. Clinical Process Recordings
    Provide excerpts of clinical process recordings with the client that are illustrative of the case.

Process Recording Examples

(Two excerpts taken from the work of a recent student in the Program, and used here with the student's permission.)

Excerpt 1

Th     Have you been able to hold a job?
DW     Yes. The longest I held a job was about six months. Or maybe it was a year. I always had so many kids... but my kids are getting older now.
Th     Was more difficult when they were younger?
DW     My favorite job was working at the Zoo...
Th     The Philadelphia Zoo? What did you do at the Zoo? [I love the zoo and am excited to find out she worked there.]
DW     I was working at the dairy barn.
Th     Oh yeah? [I know exactly where this is; I've been a good customer over the years.]
DW     When I went for the job interview, some of my kids was with me and we visited the petting zoo before the interview. I was playing and talking with lots of the kids there. The lady who interviewed me - turned out she saw us there. She said I was real good with kids. She said, "I know just the spot for you when you finish this application form." She said, "I'm gonna put you in the Dairy Barn 'cause you patient and good with kids.
You won't get mad at the kids when they stand there just going: Um.... Um.... Um...." Course in the end, most of them wanted that cookie dough. It was the most popular one. We had a whole freezer-full of that cookie dough... [She looks happy and relaxed as she talks about these positive memories of her competence.]
Th     You smile and you look very happy as you talk about this memory.
DW     Yeah.... maybe I can go back to working there when the weather gets better. I really liked working there, and they say I real good at working with the kids. I'd see one crying and he'd be lost. Every day at least one kids got lost. I'd take them down to the desk and they'd get on the speaker and make an announcement. I'd tell them, "Don't cry. Wherever they is, they're coming for you real soon, you'll see." [She sounds and looks increasingly less happy; my 'chiming in' also changes tone.]
Th     Now you sound kind of sad...
DW     I watched on the news where they shot that little boy. He was just 14 - shot a 12 year old who's in critical condition.
Th     I heard about that on the news. It's a very sad story.
DW     Shot him in the face... [She provides more details and talks about the bad neighborhood that the event occurred in and whether he will be charged as an adult or as a child.] I think they should charge the parents!

Excerpt 2

Th     You look very sad now.... This hospitalization... was it right after the twins died?
Cl     It was like 2 or 3 months later.
Th     Did you ever get depressed before the twins were born? Or just after they died...
Cl     I got depressed about 3 months later.
Th     Were you depressed between when they died and the nervous breakdown 3 months later?
Cl     I was depressed when I first heard that they died. I didn't get no chance to talk to somebody about them or nothing like that...
Th     And when was the first time you started hearing voices or seeing things?
Cl     Then.
Th     Then... after they died?
Cl     About three months later.... Every time I would see twins I would chase them...so they had to put me in the hospital....
Th     When you saw twins you were thinking...
Cl     That they was mine.... It almost killed me. You ever want something so bad and didn't get it? I wanted them girls so bad... they was supposed to be my last kids... I was supposed to get my tubes tied then... but I didn't.... But I got 2 little girls now, Virginia and 'Borah... (voice getting softer and sadder)
Th     It sounds like that was a really, really hard time for you...
Cl     It was...
Th     Before that time, did you ever have any issues with depression?
Cl     Yes, my mother used to take me to a therapist.... I used to go to the clinic on Copley Street. You know where that is? A psychiatrist... I used to go see her. I forgot her name.... it was a long time ago...
Th     That was when you were a child?
Cl     I was so young. How old was I when I had them twins? I was in my late 20's or early 30's...
Th     When you saw that psychiatrist earlier, was that in your 20's? Teens? Early teens?
Cl     I was a teenager when my mother first started taking me to see a psychiatrist....
Th     Do you remember why she took you?
Cl     Cause I used to always be down and cry all the time. She thought I had the same thing she had.
Th     What do you think? You've seen schizophrenia in your mother and your sister...
Cl     I don't think I got the same thing... schizophrenia. But there are all different types of schizophrenia...
Th     That's true. That's one of the reasons I think it's important to clarify this.... Do you ever hear voices or see things when you are not
depressed?
Cl     No.
Th     It's always when you are depressed already?
Cl     Yes...
Th     Does it ever happen when you are just a little depressed? [shakes head no] How depressed do you have to be before you start to hear voices
or see things?
Cl     At least a little depressed. That's how I know I'm getting sick again...
Th     Feeling depressed? Or the voices?
Cl     Hearing the voices. Then I know something wrong.
Th     Do you hear the voices and then you get depressed?
Cl     I already BE depressed when I hear voices... [sounds a little irritated]