GENERAL FORMAT FOR CASE PRESENTATIONS AND DISCUSSION

The purpose of these presentations and discussions is to allow you to demonstrate an example of your current field work experience and to simulate the process of collegial psychological case consultations and the professional treatment planning process.

This document includes a brief outline of the case presentation and then a longer document detailing what needs to be in each part of the case.

BRIEF OUTLINE OF CASE PRESENTATION

(this provides the general format – details of each area are provided starting on page 2)

IDemographic description of client

IIPresenting problem and reason for referral

A. Client’s perspective

B. Family perspective

C. Referring agency (or individual’s) perspective (school, legal, other agencies, etc.)

D. A summary of differences between these sources if applicable.

III The problems you are addressing in your treatment

IV History of the presenting problem

VI. General description of Client

A. Appearance

B. Behavior and psychomotor activity

C. Attitude toward examiner

VII Mood and affect

A. Mood

B. Affect

C. Appropriateness

VIII Speech (rate, quality, etc.)

IX Perceptual disturbances (hallucinations – visual, auditory, tactile, olfactory)

X. Thought

A. Process or form of thought

B. Content of thought

XI. Sensorium and cognition

A. Alertness and level of consciousness

B. Orientation

C. Memory

D. Concentration and attention

E. Capacity to read and write

F. Visuospatial ability

G Abstract thinking

XII. Impulse control

XIII. Judgment and insight

XIV Reliability

XV Results of psychological tests (if administered)

XVI Your assessment of what lead to and maintains the client’s problem (s).That is, what is your etiological/theoretical conceptualization of the client’s problems.

XVII Current diagnostic formulation:

DSM-5

XVIII Your clinical (theoretical) conceptualization of the case:

XIXSummary of services provided to date:

XXClients response to these interventions:

XXIFuture intervention changes and plans:

XXIIOther information you want to present about this case:

DETAIL OF REQUIREMENTS FOR THE CASE PRESENTATION:

Note:Please assure that all matters associated with confidentiality are strictly adhered to in your case presentation.

Demographic description of client

This section should be brief but it should leave your audience oriented to the basic demographic information about your client.

Presenting problem and reason for referral

A. Client’s perspective

B. Family perspective

C. Referring agency (or individual’s) perspective (school, legal, other agencies, etc.)

D. A summary of differences between these sources if applicable.

The problems you are addressing in your treatment

Tell your audience the problems you and your client are addressing in treatment.These may not include ALL of the problems listed in the reason for referral or all of the presenting problems.

History of the presenting problem

Think in terms the course of the problem(s) over time:

Remember that you are telling a kind of a story about your client. The events of the client’s problems unfold in a specific sequence. This sequence is referred to as the clinical time course or chronology. Think of it as the scaffold on which all the other details of the history of the problem(s) will hang. Elements of the time course should include:

• When did the problem(s) start? (Onset)
• How has it progressed over time?
• What is its current status?

Once you’ve established the time course, outline the factors that:

• make the condition worse
• relieve the condition, or make it improve
• Also – Outline any prior treatments for the condition and the condition’s response to those treatments

Initial mental status (Give your listeners an overall sense of these factors)

This is critical for inpatient clients.It is optional for other clients unless there are clear problems in certain areas that need to be delineated for your audience in order to have a more complete picture of you client.

I. General description

A. Appearance

B. Behavior and psychomotor activity

C. Attitude toward examiner

II. Mood and affect

A. Mood

B. Affect

C. Appropriateness

III. Speech (rate, quality, etc.)

IV. Perceptual disturbances (hallucinations – visual, auditory, tactile, olfactory)

*It any of these are present – please provide details about content, context and frequency.

V. Thought

A. Process or form of thought

B. Content of thought

VI. Sensorium and cognition

A. Alertness and level of consciousness

B. Orientation

C. Memory

D. Concentration and attention

E. Capacity to read and write

F. Visuospatial ability

G Abstract thinking

VII. Impulse control

VII. Judgment and insight

IX. Reliability

Results of psychological tests (if administered)

Provide us with an overview of the results of these tests and the conclusions arrived at by the tester(s). We are particularly interested in hearing about cognitive (including achievement), personality, and clinical diagnostic test results that provide us with an understanding of the clients cognitive, affective, interpersonal, and behavioral assets, limitations, and motivational dynamics.

Your assessment of what lead to and maintains the client’s problem (s).That is, what is your etiological/theoretical conceptualization of the client’s problems.

Current diagnostic formulation:

DSM-5

Your clinical (theoretical) conceptualization of the case:

What is your theoretical framework for this case.What theories have you employed to explain the presence of this condition in your client’s life?What theoretical model has driven your treatment interventions?Please include your assessment of the cultural issues that play a role in explaining and treating this case.

Summary of services provided to date:

Please summarize the various type of individual, group, family, classroom, pharmacological and other interventions as appropriate.Explain your rationale for selecting the therapeutic model(s) you have employed with your client.Also, explain your rationale for the services you have requested for your client.For example, a psychiatric and medication consultation.

Give us a feel for the process of intervention as it has unfolded since you took responsibility for the case.Provide your listeners with some sense of the sequence of these intervention.In other words – tell the story of treatment for this client so far.

Clients response to these interventions:

Give a solid sense of what progress is being made – or not being made.

Tell your listeners about any particular problems you have encountered or continue to encounter in the treatment process.

Future intervention changes and plans:

Are there modification anticipated at this point in time.How will you and the client know when treatment is no longer required?

Other information you want to present about this case:

CASE

Kareem is a 19 year old man of Middle Eastern descent.His parents immigrated to the United States for “political reasons” when he was about 2-years-old, and they have run a successful small retail business for well over a decade. He is the oldest of three children and the only son in his family.He has worked part time for his parents since he was a young adolescent.He lives with his parents, and younger sister in the home he grew up in.Another sister has recently married and lives close by in the same neighborhood. There are no other extended family members in the U.S. The family members are practicing Christians, although their involvement is to only attend Sunday services, and all are U.S. citizens.The family lives in a majority minority neighborhood with others who are originally from the same area of the world, and they maintain many of their ethnic customs.

Kareem is fluent in three languages, but considers English his primary language.His parents indicated that he had always been outgoing and friendly, and had many friends. He had started to date a nice girl after he graduated from high school.He was educated in the U.S., completed high school two years ago, and has completed one year of an associate’s degree in business program at the local community college.His family members report that he was always an exemplary student, and formerly aspired to obtain an MBA or to become an accountant and to work in the business world.He elected to attend community college part time and planned to save his own money for two years, even though his parents report they would have paid his tuition if he had elected to go to the state university immediately following high school graduation.They did acknowledge that they respect his intention to ‘be his own man’ and to still honor his family by helping with the family business while completing the first part of his college education.

Kareem was assaulted by three men nearly 10 months ago. The incident occurred late at night, as he returned home after a late study session at the community college library.In the police report, he indicated that he did not know his assailants, nor did they give any warning before attacking him.He reported hearing racial slurs as they began beating him, and considers himself the victim of a hate crime.He does not recall much about the incident, and so he has not been able to contribute much to the investigation. The case remains unsolved and to this point, it has not been categorized as a hate crime.Kareem was badly beaten, and had to be hospitalized for several weeks for multiple broken bones, a collapsed lung, and other complications of his injuries.He sustained a concussion and says he continues to have a consistent ringing in his ears since that time.He has recovered well physically, according to his father, but has many social and emotional problems following the incident.His family members are somewhat skeptical about the value of therapy, but they have been encouraged to support Kareem in seeking help by the pastor of their church. Since nothing else they have tried has worked, they are willing to try this kind of help.

Kareem was accompanied to the intake session by his father and mother.His mother spoke little during the interview unless directly addressed by the therapist, but interjected several comments indicating how proud his parents have always been of Kareem.Kareem’s father indicated while he will accompany his father to the store and will work in the back, keeping the books or making orders, Kareem will not serve customers nor will he come and go from the store on his own.His father reported that Kareem appears afraid of everything and will not take any risks. He does not go out of the house unless he is with one of his family members and he appears to be very watchful and suspicious of everyone around him the whole time he is outside the house. When at home, he is attentive to his parents’ requests and will interact appropriately, but he spends most of his time in his room, reading and listening to music, or sleeping.

He has refused to resume attending classes at the community college, and will not consider leaving home to attend the state university, and will not make application there.He has stopped seeing his friends and will not return their calls.He stopped seeing his girlfriend while still in the hospital, and no longer makes any effort to date.He refuses to go to church, tells his parents he no longer believes in God, and appears to have little interest in future plans. His parents are concerned that he has started reading some literature that is rather “extremist and violent” according to his father, and his comments about others outside his own ethnic group are increasingly negative and occasionally his comments are even hateful. His father is a pacifist and values harmony, so he considers his son’s negativity as harmful in promoting additional distance between his son and the rest of the family. He also worries that these thoughts and comments endanger him and open him up to more risks of violence.Kareem has also used some angry words in interaction with his father recently, and his father sees this as a very problematic change in his personality and a significant threat to family harmony.Because the family members have always been very close, the growing distance between them and angry interactions are painful for both parents.

It was very difficult to establish rapport with Kareem.In an individual interview without his parents present in the room, Kareem was initially willing to only answer questions with very minimal answers. He exhibited flat affect and spoke in a monotone.He was able to acknowledge the anger and fear that he currently experiences.He described the impact of the beating as “stealing my life and my hopes” and at this point, he spoke with a bitter tone of voice.He referred to the scars on his face as a reminder to everyone that he was a victim.He was able to describe symptoms of depression including loss of pleasure or satisfaction in almost every area of his life.He acknowledged that he felt helpless and regularly woke up dreaming he was being attacked again.He believes he cannot go back to school because he cannot concentrate very well.After about 15 minutes, he began to use a bit more inflection in his voice and expressed some appropriate anger.He is afraid that he has brain damage that would make it hard for him to achieve his former dreams and that it will be safer for him to stop trying.He indicated that he was glad he did not have the energy to go out and hunt down and kill his attackers as he knew that he would go to prison and this would upset and shame his parents.He then seemed to shut down his emotions again. He said the police did not care that he had been attacked, but then said, “What can you expect? They treated me like I deserved it and they probably think I’m a terriorist.”He made several comments about being tricked and manipulated, which appear to be paranoid in nature, but the intake professional decided not to pursue these as they seemed understandable, given what Kareem has been through.

Kareem has agreed to “try therapy” but it was clear that he came to the session to please his parents.He says he will do what they tell him he needs to do, and that they have indicated that he needs to come to the Psychological Center at least 3 or 4 times to try it out.His parents’ insurance coverage would allow him to receive at least 6 months of sessions. He appears to be have been able to trust the intake professional (an African American male who is trained as a psychiatric nurse) to reveal some minimal information.

As the therapist who will be treating Kareem, please address the following issues.

1. What additional information will you need to gather in order to make a diagnosis?

What diagnosis would you consider (DSM-5 diagnosis, please)?

2. What theoretical basis would you use to conceptualize the case (NOTE: the theoretical basis is NOT necessarily the same as your chosen treatment strategies and goals; the question asks for conceptualization NOT treatment).What developmental and cultural issues impact your conceptualization?Explain.

3. Given your own ethnic, gender, and other cultural features, what challenges would you anticipate in establishing rapport and beginning to work with Kareem?How would you bring these issues into your work with him?Are potential differences significant enough that you might consider referral to another therapist?Explain what might prompt you to make such a referral.

4. How much connection would you want to maintain with his family and how would you attempt to ensure that this connection has maximal impact for Kareem’s therapy? How will you address their lack of understanding of and minimal commitment to therapy for their son?What practical and ethical implications are there for involving his family or others in his treatment?

5. What treatment or intervention goals would you envision being most helpful for Kareem?Since Kareem appears to be motivated by pleasing his parents, how would you pursue setting goals that are meaningful for HIM?How do you anticipate increasing the work to more than the 3 or 4 sessions he has agreed to try?

6. Would you pursue a psychiatric consult?Why or why not?

7. What social change implications does this case bring to your attention?What actions might you take about these?