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Case Study Research in Counselling and Psychotherapy

• John McLeod - University of Oslo, Norway
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- the role of case studies in the development of theory, practice and policy in counselling and psychotherapy

- strategies for responding to moral and ethical issues in therapy case study research

- practical tools for collecting case data

- 'how-to-do-it' guides for carrying out different types of case study

- team-based case study research for practitioners and students

- questions, issues and challenges that may have been raised for readers through their study.

Concrete examples, points for reflection and discussion, and recommendations for further reading will enable readers to use the book as a basis for carrying out their own case investigation.

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This text offers students the opportunity to grasp the importance of using case studies to inform research and is recommended for our students taking an Introduction to Evidence based practice in counselling module

An excellent textbook with clear guidelines to help students understand the importance of developing consistent methods for gathering evidence as they work with cases. The role of case studies for students as they learn about the different theories is essential for them to grasp a practical understanding of applications. This book covers the knowledge of writing case reports in a clear and comprehensive way.

John McLeod is and probably always will be the author we recommend when talking about evidence based practice. His other texts in Doing Counselling Research and Qualitative Research are seminal in this context. This text fills the gap around working with case studies in research, and is very relevant as this is an area that most counsellors will need to be familiar with. The book is well written and if possible makes the subject even more approachable and interesting. Our third year students are now recommended to read this title in relation to all of the third year professional level study modules, as it offers so the opportunity to become familiar with research methodologies and language.

An excellent book which helps people understand the ethics and processes involved in a case study approach. Some very useful examples contained within the book which makes the subject understandable. It has provided me with the motivation to consider applying this in my own practice.

Part of the beauty of this book is the accessibility of the author; as he brings the reader through an exciting, interesting, pragmatic and richly informed account of living qualitative research in action. The book considers; pragmatic, n=1, HSCED, theory-building adn one of my personal favourites - narrative approaches. This book is a required resource for anyone interested in qualitative research or therapy practice. A gem.

A thorough and rigorous review of the latest developments in case study research. Important reading for all counselling and psychotherapy research students, and practitioners who want to write up their clinical work.

This is a useful book, that makes a considered case for the the use of Case Studies for effective research as well as a developmental method for students.

Excellent book, which fills a gap in the current literature; especially useful in clinical psychology training where alternatives to n=1 empirical case studies are not widely accepted.

this has everything that you need for researching

This book has been useful in thinking about revalidation the Social Work degree and its themes will take a more central part in the revalidated degree from 2011-12 onwards.

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Foreword by Daniel B. Fishman, Ph.D., Rutgers University

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• Psicol Reflex Crit
• v.34; 2021 Dec

Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE)

Greta kaluzeviciute.

Department of Psychosocial and Psychoanalytic Studies, University of Essex, Wivenhoe Park, Colchester, CO4 3SQ UK

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Systematic case studies are often placed at the low end of evidence-based practice (EBP) due to lack of critical appraisal. This paper seeks to attend to this research gap by introducing a novel Case Study Evaluation-tool (CaSE). First, issues around knowledge generation and validity are assessed in both EBP and practice-based evidence (PBE) paradigms. Although systematic case studies are more aligned with PBE paradigm, the paper argues for a complimentary, third way approach between the two paradigms and their ‘exemplary’ methodologies: case studies and randomised controlled trials (RCTs). Second, the paper argues that all forms of research can produce ‘valid evidence’ but the validity itself needs to be assessed against each specific research method and purpose. Existing appraisal tools for qualitative research (JBI, CASP, ETQS) are shown to have limited relevance for the appraisal of systematic case studies through a comparative tool assessment. Third, the paper develops purpose-oriented evaluation criteria for systematic case studies through CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose-based Evaluative Framework for Systematic Case Studies. The checklist approach aids reviewers in assessing the presence or absence of essential case study components (internal validity). The framework approach aims to assess the effectiveness of each case against its set out research objectives and aims (external validity), based on different systematic case study purposes in psychotherapy. Finally, the paper demonstrates the application of the tool with a case example and notes further research trajectories for the development of CaSE tool.

Introduction

Due to growing demands of evidence-based practice, standardised research assessment and appraisal tools have become common in healthcare and clinical treatment (Hannes, Lockwood, & Pearson, 2010 ; Hartling, Chisholm, Thomson, & Dryden, 2012 ; Katrak, Bialocerkowski, Massy-Westropp, Kumar, & Grimmer, 2004 ). This allows researchers to critically appraise research findings on the basis of their validity, results, and usefulness (Hill & Spittlehouse, 2003 ). Despite the upsurge of critical appraisal in qualitative research (Williams, Boylan, & Nunan, 2019 ), there are no assessment or appraisal tools designed for psychotherapy case studies.

Although not without controversies (Michels, 2000 ), case studies remain central to the investigation of psychotherapy processes (Midgley, 2006 ; Willemsen, Della Rosa, & Kegerreis, 2017 ). This is particularly true of systematic case studies, the most common form of case study in contemporary psychotherapy research (Davison & Lazarus, 2007 ; McLeod & Elliott, 2011 ).

Unlike the classic clinical case study, systematic cases usually involve a team of researchers, who gather data from multiple different sources (e.g., questionnaires, observations by the therapist, interviews, statistical findings, clinical assessment, etc.), and involve a rigorous data triangulation process to assess whether the data from different sources converge (McLeod, 2010 ). Since systematic case studies are methodologically pluralistic, they have a greater interest in situating patients within the study of a broader population than clinical case studies (Iwakabe & Gazzola, 2009 ). Systematic case studies are considered to be an accessible method for developing research evidence-base in psychotherapy (Widdowson, 2011 ), especially since they correct some of the methodological limitations (e.g. lack of ‘third party’ perspectives and bias in data analysis) inherent to classic clinical case studies (Iwakabe & Gazzola, 2009 ). They have been used for the purposes of clinical training (Tuckett, 2008 ), outcome assessment (Hilliard, 1993 ), development of clinical techniques (Almond, 2004 ) and meta-analysis of qualitative findings (Timulak, 2009 ). All these developments signal a revived interest in the case study method, but also point to the obvious lack of a research assessment tool suitable for case studies in psychotherapy (Table ​ (Table1 1 ).

Key concept: systematic case study

To attend to this research gap, this paper first reviews issues around the conceptualisation of validity within the paradigms of evidence-based practice (EBP) and practice-based evidence (PBE). Although case studies are often positioned at the low end of EBP (Aveline, 2005 ), the paper suggests that systematic cases are a valuable form of evidence, capable of complimenting large-scale studies such as randomised controlled trials (RCTs). However, there remains a difficulty in assessing the quality and relevance of case study findings to broader psychotherapy research.

As a way forward, the paper introduces a novel Case Study Evaluation-tool (CaSE) in the form of CaSE Purpose - based Evaluative Framework for Systematic Case Studies and CaSE Checklist for Essential Components in Systematic Case Studies . The long-term development of CaSE would contribute to psychotherapy research and practice in three ways.

Given the significance of methodological pluralism and diverse research aims in systematic case studies, CaSE will not seek to prescribe explicit case study writing guidelines, which has already been done by numerous authors (McLeod, 2010 ; Meganck, Inslegers, Krivzov, & Notaerts, 2017 ; Willemsen et al., 2017 ). Instead, CaSE will enable the retrospective assessment of systematic case study findings and their relevance (or lack thereof) to broader psychotherapy research and practice. However, there is no reason to assume that CaSE cannot be used prospectively (i.e. producing systematic case studies in accordance to CaSE evaluative framework, as per point 3 in Table ​ Table2 2 ).

How can Case Study Evaluation-tool (CaSE) be used in psychotherapy research and practice?

The development of a research assessment or appraisal tool is a lengthy, ongoing process (Long & Godfrey, 2004 ). It is particularly challenging to develop a comprehensive purpose - oriented evaluative framework, suitable for the assessment of diverse methodologies, aims and outcomes. As such, this paper should be treated as an introduction to the broader development of CaSE tool. It will introduce the rationale behind CaSE and lay out its main approach to evidence and evaluation, with further development in mind. A case example from the Single Case Archive (SCA) ( https://singlecasearchive.com ) will be used to demonstrate the application of the tool ‘in action’. The paper notes further research trajectories and discusses some of the limitations around the use of the tool.

Separating the wheat from the chaff: what is and is not evidence in psychotherapy (and who gets to decide?)

The common approach: evidence-based practice.

In the last two decades, psychotherapy has become increasingly centred around the idea of an evidence-based practice (EBP). Initially introduced in medicine, EBP has been defined as ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996 ). EBP revolves around efficacy research: it seeks to examine whether a specific intervention has a causal (in this case, measurable) effect on clinical populations (Barkham & Mellor-Clark, 2003 ). From a conceptual standpoint, Sackett and colleagues defined EBP as a paradigm that is inclusive of many methodologies, so long as they contribute towards clinical decision-making process and accumulation of best currently available evidence in any given set of circumstances (Gabbay & le May, 2011 ). Similarly, the American Psychological Association (APA, 2010 ) has recently issued calls for evidence-based systematic case studies in order to produce standardised measures for evaluating process and outcome data across different therapeutic modalities.

However, given EBP’s focus on establishing cause-and-effect relationships (Rosqvist, Thomas, & Truax, 2011 ), it is unsurprising that qualitative research is generally not considered to be ‘gold standard’ or ‘efficacious’ within this paradigm (Aveline, 2005 ; Cartwright & Hardie, 2012 ; Edwards, 2013 ; Edwards, Dattilio, & Bromley, 2004 ; Longhofer, Floersch, & Hartmann, 2017 ). Qualitative methods like systematic case studies maintain an appreciation for context, complexity and meaning making. Therefore, instead of measuring regularly occurring causal relations (as in quantitative studies), the focus is on studying complex social phenomena (e.g. relationships, events, experiences, feelings, etc.) (Erickson, 2012 ; Maxwell, 2004 ). Edwards ( 2013 ) points out that, although context-based research in systematic case studies is the bedrock of psychotherapy theory and practice, it has also become shrouded by an unfortunate ideological description: ‘anecdotal’ case studies (i.e. unscientific narratives lacking evidence, as opposed to ‘gold standard’ evidence, a term often used to describe the RCT method and the therapeutic modalities supported by it), leading to a further need for advocacy in and defence of the unique epistemic process involved in case study research (Fishman, Messer, Edwards, & Dattilio, 2017 ).

The EBP paradigm prioritises the quantitative approach to causality, most notably through its focus on high generalisability and the ability to deal with bias through randomisation process. These conditions are associated with randomised controlled trials (RCTs) but are limited (or, as some argue, impossible) in qualitative research methods such as the case study (Margison et al., 2000 ) (Table ​ (Table3 3 ).

Key concept: evidence-based practice (EBP)

‘Evidence’ from an EBP standpoint hovers over the epistemological assumption of procedural objectivity : knowledge can be generated in a standardised, non-erroneous way, thus producing objective (i.e. with minimised bias) data. This can be achieved by anyone, as long as they are able to perform the methodological procedure (e.g. RCT) appropriately, in a ‘clearly defined and accepted process that assists with knowledge production’ (Douglas, 2004 , p. 131). If there is a well-outlined quantitative form for knowledge production, the same outcome should be achieved regardless of who processes or interprets the information. For example, researchers using Cochrane Review assess the strength of evidence using meticulously controlled and scrupulous techniques; in turn, this minimises individual judgment and creates unanimity of outcomes across different groups of people (Gabbay & le May, 2011 ). The typical process of knowledge generation (through employing RCTs and procedural objectivity) in EBP is demonstrated in Fig. ​ Fig.1 1 .

Typical knowledge generation process in evidence–based practice (EBP)

In EBP, the concept of validity remains somewhat controversial, with many critics stating that it limits rather than strengthens knowledge generation (Berg, 2019 ; Berg & Slaattelid, 2017 ; Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013 ). This is because efficacy research relies on internal validity . At a general level, this concept refers to the congruence between the research study and the research findings (i.e. the research findings were not influenced by anything external to the study, such as confounding variables, methodological errors and bias); at a more specific level, internal validity determines the extent to which a study establishes a reliable causal relationship between an independent variable (e.g. treatment) and independent variable (outcome or effect) (Margison et al., 2000 ). This approach to validity is demonstrated in Fig. ​ Fig.2 2 .

Internal validity

Social scientists have argued that there is a trade-off between research rigour and generalisability: the more specific the sample and the more rigorously defined the intervention, the outcome is likely to be less applicable to everyday, routine practice. As such, there remains a tension between employing procedural objectivity which increases the rigour of research outcomes and applying such outcomes to routine psychotherapy practice where scientific standards of evidence are not uniform.

According to McLeod ( 2002 ), inability to address questions that are most relevant for practitioners contributed to a deepening research–practice divide in psychotherapy. Studies investigating how practitioners make clinical decisions and the kinds of evidence they refer to show that there is a strong preference for knowledge that is not generated procedurally, i.e. knowledge that encompasses concrete clinical situations, experiences and techniques. A study by Stewart and Chambless ( 2007 ) sought to assess how a larger population of clinicians (under APA, from varying clinical schools of thought and independent practices, sample size 591) make treatment decisions in private practice. The study found that large-scale statistical data was not the primary source of information sought by clinicians. The most important influences were identified as past clinical experiences and clinical expertise ( M = 5.62). Treatment materials based on clinical case observations and theory ( M = 4.72) were used almost as frequently as psychotherapy outcome research findings ( M = 4.80) (i.e. evidence-based research). These numbers are likely to fluctuate across different forms of psychotherapy; however, they are indicative of the need for research about routine clinical settings that does not isolate or generalise the effect of an intervention but examines the variations in psychotherapy processes.

The alternative approach: practice-based evidence

In an attempt to dissolve or lessen the research–practice divide, an alternative paradigm of practice-based evidence (PBE) has been suggested (Barkham & Mellor-Clark, 2003 ; Fox, 2003 ; Green & Latchford, 2012 ; Iwakabe & Gazzola, 2009 ; Laska, Motulsky, Wertz, Morrow, & Ponterotto, 2014 ; Margison et al., 2000 ). PBE represents a shift in how we think about evidence and knowledge generation in psychotherapy. PBE treats research as a local and contingent process (at least initially), which means it focuses on variations (e.g. in patient symptoms) and complexities (e.g. of clinical setting) in the studied phenomena (Fox, 2003 ). Moreover, research and theory-building are seen as complementary rather than detached activities from clinical practice. That is to say, PBE seeks to examine how and which treatments can be improved in everyday clinical practice by flagging up clinically salient issues and developing clinical techniques (Barkham & Mellor-Clark, 2003 ). For this reason, PBE is concerned with the effectiveness of research findings: it evaluates how well interventions work in real-world settings (Rosqvist et al., 2011 ). Therefore, although it is not unlikely for RCTs to be used in order to generate practice-informed evidence (Horn & Gassaway, 2007 ), qualitative methods like the systematic case study are seen as ideal for demonstrating the effectiveness of therapeutic interventions with individual patients (van Hennik, 2020 ) (Table ​ (Table4 4 ).

Key concept: practice-based evidence (PBE)

PBE’s epistemological approach to ‘evidence’ may be understood through the process of concordant objectivity (Douglas, 2004 ): ‘Instead of seeking to eliminate individual judgment, … [concordant objectivity] checks to see whether the individual judgments of people in fact do agree’ (p. 462). This does not mean that anyone can contribute to the evaluation process like in procedural objectivity, where the main criterion is following a set quantitative protocol or knowing how to operate a specific research design. Concordant objectivity requires that there is a set of competent observers who are closely familiar with the studied phenomenon (e.g. researchers and practitioners who are familiar with depression from a variety of therapeutic approaches).

Systematic case studies are a good example of PBE ‘in action’: they allow for the examination of detailed unfolding of events in psychotherapy practice, making it the most pragmatic and practice-oriented form of psychotherapy research (Fishman, 1999 , 2005 ). Furthermore, systematic case studies approach evidence and results through concordant objectivity (Douglas, 2004 ) by involving a team of researchers and rigorous data triangulation processes (McLeod, 2010 ). This means that, although systematic case studies remain focused on particular clinical situations and detailed subjective experiences (similar to classic clinical case studies; see Iwakabe & Gazzola, 2009 ), they still involve a series of validity checks and considerations on how findings from a single systematic case pertain to broader psychotherapy research (Fishman, 2005 ). The typical process of knowledge generation (through employing systematic case studies and concordant objectivity) in PBE is demonstrated in Fig. ​ Fig.3. 3 . The figure exemplifies a bidirectional approach to research and practice, which includes the development of research-supported psychological treatments (through systematic reviews of existing evidence) as well as the perspectives of clinical practitioners in the research process (through the study of local and contingent patient and/or treatment processes) (Teachman et al., 2012 ; Westen, Novotny, & Thompson-Brenner, 2004 ).

Typical knowledge generation process in practice-based evidence (PBE)

From a PBE standpoint, external validity is a desirable research condition: it measures extent to which the impact of interventions apply to real patients and therapists in everyday clinical settings. As such, external validity is not based on the strength of causal relationships between treatment interventions and outcomes (as in internal validity); instead, the use of specific therapeutic techniques and problem-solving decisions are considered to be important for generalising findings onto routine clinical practice (even if the findings are explicated from a single case study; see Aveline, 2005 ). This approach to validity is demonstrated in Fig. ​ Fig.4 4 .

External validity

Since effectiveness research is less focused on limiting the context of the studied phenomenon (indeed, explicating the context is often one of the research aims), there is more potential for confounding factors (e.g. bias and uncontrolled variables) which in turn can reduce the study’s internal validity (Barkham & Mellor-Clark, 2003 ). This is also an important challenge for research appraisal. Douglas ( 2004 ) argues that appraising research in terms of its effectiveness may produce significant disagreements or group illusions, since what might work for some practitioners may not work for others: ‘It cannot guarantee that values are not influencing or supplanting reasoning; the observers may have shared values that cause them to all disregard important aspects of an event’ (Douglas, 2004 , p. 462). Douglas further proposes that an interactive approach to objectivity may be employed as a more complex process in debating the evidential quality of a research study: it requires a discussion among observers and evaluators in the form of peer-review, scientific discourse, as well as research appraisal tools and instruments. While these processes of rigour are also applied in EBP, there appears to be much more space for debate, disagreement and interpretation in PBE’s approach to research evaluation, partly because the evaluation criteria themselves are subject of methodological debate and are often employed in different ways by researchers (Williams et al., 2019 ). This issue will be addressed more explicitly again in relation to CaSE development (‘Developing purpose-oriented evaluation criteria for systematic case studies’ section).

A third way approach to validity and evidence

The research–practice divide shows us that there may be something significant in establishing complementarity between EBP and PBE rather than treating them as mutually exclusive forms of research (Fishman et al., 2017 ). For one, EBP is not a sufficient condition for delivering research relevant to practice settings (Bower, 2003 ). While RCTs can demonstrate that an intervention works on average in a group, clinicians who are facing individual patients need to answer a different question: how can I make therapy work with this particular case ? (Cartwright & Hardie, 2012 ). Systematic case studies are ideal for filling this gap: they contain descriptions of microprocesses (e.g. patient symptoms, therapeutic relationships, therapist attitudes) in psychotherapy practice that are often overlooked in large-scale RCTs (Iwakabe & Gazzola, 2009 ). In particular, systematic case studies describing the use of specific interventions with less researched psychological conditions (e.g. childhood depression or complex post-traumatic stress disorder) can deepen practitioners’ understanding of effective clinical techniques before the results of large-scale outcome studies are disseminated.

Secondly, establishing a working relationship between systematic case studies and RCTs will contribute towards a more pragmatic understanding of validity in psychotherapy research. Indeed, the very tension and so-called trade-off between internal and external validity is based on the assumption that research methods are designed on an either/or basis; either they provide a sufficiently rigorous study design or they produce findings that can be applied to real-life practice. Jimenez-Buedo and Miller ( 2010 ) call this assumption into question: in their view, if a study is not internally valid, then ‘little, or rather nothing, can be said of the outside world’ (p. 302). In this sense, internal validity may be seen as a pre-requisite for any form of applied research and its external validity, but it need not be constrained to the quantitative approach of causality. For example, Levitt, Motulsky, Wertz, Morrow, and Ponterotto ( 2017 ) argue that, what is typically conceptualised as internal validity, is, in fact, a much broader construct, involving the assessment of how the research method (whether qualitative or quantitative) is best suited for the research goal, and whether it obtains the relevant conclusions. Similarly, Truijens, Cornelis, Desmet, and De Smet ( 2019 ) suggest that we should think about validity in a broader epistemic sense—not just in terms of psychometric measures, but also in terms of the research design, procedure, goals (research questions), approaches to inquiry (paradigms, epistemological assumptions), etc.

The overarching argument from research cited above is that all forms of research—qualitative and quantitative—can produce ‘valid evidence’ but the validity itself needs to be assessed against each specific research method and purpose. For example, RCTs are accompanied with a variety of clearly outlined appraisal tools and instruments such as CASP (Critical Appraisal Skills Programme) that are well suited for the assessment of RCT validity and their implications for EBP. Systematic case studies (or case studies more generally) currently have no appraisal tools in any discipline. The next section evaluates whether existing qualitative research appraisal tools are relevant for systematic case studies in psychotherapy and specifies the missing evaluative criteria.

The relevance of existing appraisal tools for qualitative research to systematic case studies in psychotherapy

What is a research tool.

Currently, there are several research appraisal tools, checklists and frameworks for qualitative studies. It is important to note that tools, checklists and frameworks are not equivalent to one another but actually refer to different approaches to appraising the validity of a research study. As such, it is erroneous to assume that all forms of qualitative appraisal feature the same aims and methods (Hannes et al., 2010 ; Williams et al., 2019 ).

Generally, research assessment falls into two categories: checklists and frameworks . Checklist approaches are often contrasted with quantitative research, since the focus is on assessing the internal validity of research (i.e. researcher’s independence from the study). This involves the assessment of bias in sampling, participant recruitment, data collection and analysis. Framework approaches to research appraisal, on the other hand, revolve around traditional qualitative concepts such as transparency, reflexivity, dependability and transferability (Williams et al., 2019 ). Framework approaches to appraisal are often challenging to use because they depend on the reviewer’s familiarisation and interpretation of the qualitative concepts.

Because of these different approaches, there is some ambiguity in terminology, particularly between research appraisal instruments and research appraisal tools . These terms are often used interchangeably in appraisal literature (Williams et al., 2019 ). In this paper, research appraisal tool is defined as a method-specific (i.e. it identifies a specific research method or component) form of appraisal that draws from both checklist and framework approaches. Furthermore, a research appraisal tool seeks to inform decision making in EBP or PBE paradigms and provides explicit definitions of the tool’s evaluative framework (thus minimising—but by no means eliminating—the reviewers’ interpretation of the tool). This definition will be applied to CaSE (Table ​ (Table5 5 ).

Key concept: research appraisal tool

In contrast, research appraisal instruments are generally seen as a broader form of appraisal in the sense that they may evaluate a variety of methods (i.e. they are non-method specific or they do not target a particular research component), and are aimed at checking whether the research findings and/or the study design contain specific elements (e.g. the aims of research, the rationale behind design methodology, participant recruitment strategies, etc.).

There is often an implicit difference in audience between appraisal tools and instruments. Research appraisal instruments are often aimed at researchers who want to assess the strength of their study; however, the process of appraisal may not be made explicit in the study itself (besides mentioning that the tool was used to appraise the study). Research appraisal tools are aimed at researchers who wish to explicitly demonstrate the evidential quality of the study to the readers (which is particularly common in RCTs). All forms of appraisal used in the comparative exercise below are defined as ‘tools’, even though they have different appraisal approaches and aims.

Comparing different qualitative tools

Hannes et al. ( 2010 ) identified CASP (Critical Appraisal Skills Programme-tool), JBI (Joanna Briggs Institute-tool) and ETQS (Evaluation Tool for Qualitative Studies) as the most frequently used critical appraisal tools by qualitative researchers. All three instruments are available online and are free of charge, which means that any researcher or reviewer can readily utilise CASP, JBI or ETQS evaluative frameworks to their research. Furthermore, all three instruments were developed within the context of organisational, institutional or consortium support (Tables ​ (Tables6, 6 , ​ ,7 7 and ​ and8 8 ).

CASP (Critical Appraisal Skills Programme-tool)

JBI (Joanna Briggs Institute-tool)

ETQS (Evaluation Tool for Qualitative Studies)

It is important to note that neither of the three tools is specific to systematic case studies or psychotherapy case studies (which would include not only systematic but also experimental and clinical cases). This means that using CASP, JBI or ETQS for case study appraisal may come at a cost of overlooking elements and components specific to the systematic case study method.

Based on Hannes et al. ( 2010 ) comparative study of qualitative appraisal tools as well as the different evaluation criteria explicated in CASP, JBI and ETQS evaluative frameworks, I assessed how well each of the three tools is attuned to the methodological , clinical and theoretical aspects of systematic case studies in psychotherapy. The latter components were based on case study guidelines featured in the journal of Pragmatic Case Studies in Psychotherapy as well as components commonly used by published systematic case studies across a variety of other psychotherapy journals (e.g. Psychotherapy Research , Research In Psychotherapy : Psychopathology Process And Outcome , etc.) (see Table ​ Table9 9 for detailed descriptions of each component).

Comparing the relevance of JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies) for appraising components specific to systematic case studies

The evaluation criteria for each tool in Table ​ Table9 9 follows Joanna Briggs Institute (JBI) ( 2017a , 2017b ); Critical Appraisal Skills Programme (CASP) ( 2018 ); and ETQS Questionnaire (first published in 2004 but revised continuously since). Table ​ Table10 10 demonstrates how each tool should be used (i.e. recommended reviewer responses to checklists and questionnaires).

Recommended reviewer responses to JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies)

Using CASP, JBI and ETQS for systematic case study appraisal

Although JBI, CASP and ETQS were all developed to appraise qualitative research, it is evident from the above comparison that there are significant differences between the three tools. For example, JBI and ETQS are well suited to assess researcher’s interpretations (Hannes et al. ( 2010 ) defined this as interpretive validity , a subcategory of internal validity ): the researcher’s ability to portray, understand and reflect on the research participants’ experiences, thoughts, viewpoints and intentions. JBI has an explicit requirement for participant voices to be clearly represented, whereas ETQS involves a set of questions about key characteristics of events, persons, times and settings that are relevant to the study. Furthermore, both JBI and ETQS seek to assess the researcher’s influence on the research, with ETQS particularly focusing on the evaluation of reflexivity (the researcher’s personal influence on the interpretation and collection of data). These elements are absent or addressed to a lesser extent in the CASP tool.

The appraisal of transferability of findings (what this paper previously referred to as external validity ) is addressed only by ETQS and CASP. Both tools have detailed questions about the value of research to practice and policy as well as its transferability to other populations and settings. Methodological research aspects are also extensively addressed by CASP and ETQS, but less so by JBI (which relies predominantly on congruity between research methodology and objectives without any particular assessment criteria for other data sources and/or data collection methods). Finally, the evaluation of theoretical aspects (referred to by Hannes et al. ( 2010 ) as theoretical validity ) is addressed only by JBI and ETQS; there are no assessment criteria for theoretical framework in CASP.

Given these differences, it is unsurprising that CASP, JBI and ETQS have limited relevance for systematic case studies in psychotherapy. First, it is evident that neither of the three tools has specific evaluative criteria for the clinical component of systematic case studies. Although JBI and ETQS feature some relevant questions about participants and their context, the conceptualisation of patients (and/or clients) in psychotherapy involves other kinds of data elements (e.g. diagnostic tools and questionnaires as well as therapist observations) that go beyond the usual participant data. Furthermore, much of the clinical data is intertwined with the therapist’s clinical decision-making and thinking style (Kaluzeviciute & Willemsen, 2020 ). As such, there is a need to appraise patient data and therapist interpretations not only on a separate basis, but also as two forms of knowledge that are deeply intertwined in the case narrative.

Secondly, since systematic case studies involve various forms of data, there is a need to appraise how these data converge (or how different methods complement one another in the case context) and how they can be transferred or applied in broader psychotherapy research and practice. These systematic case study components are attended to a degree by CASP (which is particularly attentive of methodological components) and ETQS (particularly specific criteria for research transferability onto policy and practice). These components are not addressed or less explicitly addressed by JBI. Overall, neither of the tools is attuned to all methodological, theoretical and clinical components of the systematic case study. Specifically, there are no clear evaluation criteria for the description of research teams (i.e. different data analysts and/or clinicians); the suitability of the systematic case study method; the description of patient’s clinical assessment; the use of other methods or data sources; the general data about therapeutic progress.

Finally, there is something to be said about the recommended reviewer responses (Table ​ (Table10). 10 ). Systematic case studies can vary significantly in their formulation and purpose. The methodological, theoretical and clinical components outlined in Table ​ Table9 9 follow guidelines made by case study journals; however, these are recommendations, not ‘set in stone’ case templates. For this reason, the straightforward checklist approaches adopted by JBI and CASP may be difficult to use for case study researchers and those reviewing case study research. The ETQS open-ended questionnaire approach suggested by Long and Godfrey ( 2004 ) enables a comprehensive, detailed and purpose-oriented assessment, suitable for the evaluation of systematic case studies. That said, there remains a challenge of ensuring that there is less space for the interpretation of evaluative criteria (Williams et al., 2019 ). The combination of checklist and framework approaches would, therefore, provide a more stable appraisal process across different reviewers.

Developing purpose-oriented evaluation criteria for systematic case studies

The starting point in developing evaluation criteria for Case Study Evaluation-tool (CaSE) is addressing the significance of pluralism in systematic case studies. Unlike RCTs, systematic case studies are pluralistic in the sense that they employ divergent practices in methodological procedures ( research process ), and they may include significantly different research aims and purpose ( the end - goal ) (Kaluzeviciute & Willemsen, 2020 ). While some systematic case studies will have an explicit intention to conceptualise and situate a single patient’s experiences and symptoms within a broader clinical population, others will focus on the exploration of phenomena as they emerge from the data. It is therefore important that CaSE is positioned within a purpose - oriented evaluative framework , suitable for the assessment of what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). This approach to evidence and appraisal is in line with the PBE paradigm. PBE emphasises the study of clinical complexities and variations through local and contingent settings (e.g. single case studies) and promotes methodological pluralism (Barkham & Mellor-Clark, 2003 ).

CaSE checklist for essential components in systematic case studies

In order to conceptualise purpose-oriented appraisal questions, we must first look at what unites and differentiates systematic case studies in psychotherapy. The commonly used theoretical, clinical and methodological systematic case study components were identified earlier in Table ​ Table9. 9 . These components will be seen as essential and common to most systematic case studies in CaSE evaluative criteria. If these essential components are missing in a systematic case study, then it may be implied there is a lack of information, which in turn diminishes the evidential quality of the case. As such, the checklist serves as a tool for checking whether a case study is, indeed, systematic (as opposed to experimental or clinical; see Iwakabe & Gazzola, 2009 for further differentiation between methodologically distinct case study types) and should be used before CaSE Purpose - based Evaluative Framework for Systematic Case Studie s (which is designed for the appraisal of different purposes common to systematic case studies).

As noted earlier in the paper, checklist approaches to appraisal are useful when evaluating the presence or absence of specific information in a research study. This approach can be used to appraise essential components in systematic case studies, as shown below. From a pragmatic point view (Levitt et al., 2017 ; Truijens et al., 2019 ), CaSE Checklist for Essential Components in Systematic Case Studies can be seen as a way to ensure the internal validity of systematic case study: the reviewer is assessing whether sufficient information is provided about the case design, procedure, approaches to inquiry, etc., and whether they are relevant to the researcher’s objectives and conclusions (Table ​ (Table11 11 ).

Case Study Evaluation-tool (CaSE) checklist for essential components in systematic case studies. Recommended responses: Yes, No, unclear or not applicable

CaSE purpose-based evaluative framework for systematic case studies

Identifying differences between systematic case studies means identifying the different purposes systematic case studies have in psychotherapy. Based on the earlier work by social scientist Yin ( 1984 , 1993 ), we can differentiate between exploratory (hypothesis generating, indicating a beginning phase of research), descriptive (particularising case data as it emerges) and representative (a case that is typical of a broader clinical population, referred to as the ‘explanatory case’ by Yin) cases.

Another increasingly significant strand of systematic case studies is transferable (aggregating and transferring case study findings) cases. These cases are based on the process of meta-synthesis (Iwakabe & Gazzola, 2009 ): by examining processes and outcomes in many different case studies dealing with similar clinical issues, researchers can identify common themes and inferences. In this way, single case studies that have relatively little impact on clinical practice, research or health care policy (in the sense that they capture psychotherapy processes rather than produce generalisable claims as in Yin’s representative case studies) can contribute to the generation of a wider knowledge base in psychotherapy (Iwakabe, 2003 , 2005 ). However, there is an ongoing issue of assessing the evidential quality of such transferable cases. According to Duncan and Sparks ( 2020 ), although meta-synthesis and meta-analysis are considered to be ‘gold standard’ for assessing interventions across disparate studies in psychotherapy, they often contain case studies with significant research limitations, inappropriate interpretations and insufficient information. It is therefore important to have a research appraisal process in place for selecting transferable case studies.

Two other types of systematic case study research include: critical (testing and/or confirming existing theories) cases, which are described as an excellent method for falsifying existing theoretical concepts and testing whether therapeutic interventions work in practice with concrete patients (Kaluzeviciute, 2021 ), and unique (going beyond the ‘typical’ cases and demonstrating deviations) cases (Merriam, 1998 ). These two systematic case study types are often seen as less valuable for psychotherapy research given that unique/falsificatory findings are difficult to generalise. But it is clear that practitioners and researchers in our field seek out context-specific data, as well as detailed information on the effectiveness of therapeutic techniques in single cases (Stiles, 2007 ) (Table ​ (Table12 12 ).

Key concept: purpose–based systematic case studies

Each purpose-based case study contributes to PBE in different ways. Representative cases provide qualitatively rich, in-depth data about a clinical phenomenon within its particular context. This offers other clinicians and researchers access to a ‘closed world’ (Mackrill & Iwakabe, 2013 ) containing a wide range of attributes about a conceptual type (e.g. clinical condition or therapeutic technique). Descriptive cases generally seek to demonstrate a realistic snapshot of therapeutic processes, including complex dynamics in therapeutic relationships, and instances of therapeutic failure (Maggio, Molgora, & Oasi, 2019 ). Data in descriptive cases should be presented in a transparent manner (e.g. if there are issues in standardising patient responses to a self-report questionnaire, this should be made explicit). Descriptive cases are commonly used in psychotherapy training and supervision. Unique cases are relevant for both clinicians and researchers: they often contain novel treatment approaches and/or introduce new diagnostic considerations about patients who deviate from the clinical population. Critical cases demonstrate the application of psychological theories ‘in action’ with particular patients; as such, they are relevant to clinicians, researchers and policymakers (Mackrill & Iwakabe, 2013 ). Exploratory cases bring new insight and observations into clinical practice and research. This is particularly useful when comparing (or introducing) different clinical approaches and techniques (Trad & Raine, 1994 ). Findings from exploratory cases often include future research suggestions. Finally, transferable cases provide one solution to the generalisation issue in psychotherapy research through the previously mentioned process of meta-synthesis. Grouped together, transferable cases can contribute to theory building and development, as well as higher levels of abstraction about a chosen area of psychotherapy research (Iwakabe & Gazzola, 2009 ).

With this plurality in mind, it is evident that CaSE has a challenging task of appraising research components that are distinct across six different types of purpose-based systematic case studies. The purpose-specific evaluative criteria in Table ​ Table13 13 was developed in close consultation with epistemological literature associated with each type of case study, including: Yin’s ( 1984 , 1993 ) work on establishing the typicality of representative cases; Duncan and Sparks’ ( 2020 ) and Iwakabe and Gazzola’s ( 2009 ) case selection criteria for meta-synthesis and meta-analysis; Stake’s ( 1995 , 2010 ) research on particularising case narratives; Merriam’s ( 1998 ) guidelines on distinctive attributes of unique case studies; Kennedy’s ( 1979 ) epistemological rules for generalising from case studies; Mahrer’s ( 1988 ) discovery oriented case study approach; and Edelson’s ( 1986 ) guidelines for rigorous hypothesis generation in case studies.

Case Study Evaluation-tool (CaSE) purpose-based evaluative framework for systematic case studies. Recommended responses: open-ended questionnaire

Research on epistemic issues in case writing (Kaluzeviciute, 2021 ) and different forms of scientific thinking in psychoanalytic case studies (Kaluzeviciute & Willemsen, 2020 ) was also utilised to identify case study components that would help improve therapist clinical decision-making and reflexivity.

For the analysis of more complex research components (e.g. the degree of therapist reflexivity), the purpose-based evaluation will utilise a framework approach, in line with comprehensive and open-ended reviewer responses in ETQS (Evaluation Tool for Qualitative Studies) (Long & Godfrey, 2004 ) (Table ​ (Table13). 13 ). That is to say, the evaluation here is not so much about the presence or absence of information (as in the checklist approach) but the degree to which the information helps the case with its unique purpose, whether it is generalisability or typicality. Therefore, although the purpose-oriented evaluation criteria below encompasses comprehensive questions at a considerable level of generality (in the sense that not all components may be required or relevant for each case study), it nevertheless seeks to engage with each type of purpose-based systematic case study on an individual basis (attending to research or clinical components that are unique to each of type of case study).

It is important to note that, as this is an introductory paper to CaSE, the evaluative framework is still preliminary: it involves some of the core questions that pertain to the nature of all six purpose-based systematic case studies. However, there is a need to develop a more comprehensive and detailed CaSE appraisal framework for each purpose-based systematic case study in the future.

Using CaSE on published systematic case studies in psychotherapy: an example

To illustrate the use of CaSE Purpose - based Evaluative Framework for Systematic Case Studies , a case study by Lunn, Daniel, and Poulsen ( 2016 ) titled ‘ Psychoanalytic Psychotherapy With a Client With Bulimia Nervosa ’ was selected from the Single Case Archive (SCA) and analysed in Table ​ Table14. 14 . Based on the core questions associated with the six purpose-based systematic case study types in Table ​ Table13(1 13 (1 to 6), the purpose of Lunn et al.’s ( 2016 ) case was identified as critical (testing an existing theoretical suggestion).

Using Case Study Evaluation-tool (CaSE): Lunn et al. ( 2016 )’s case ‘ Psychoanalytic psychotherapy with a client with bulimia nervosa ’

Sometimes, case study authors will explicitly define the purpose of their case in the form of research objectives (as was the case in Lunn et al.’s study); this helps identifying which purpose-based questions are most relevant for the evaluation of the case. However, some case studies will require comprehensive analysis in order to identify their purpose (or multiple purposes). As such, it is recommended that CaSE reviewers first assess the degree and manner in which information about the studied phenomenon, patient data, clinical discourse and research are presented before deciding on the case purpose.

Although each purpose-based systematic case study will contribute to different strands of psychotherapy (theory, practice, training, etc.) and focus on different forms of data (e.g. theory testing vs extensive clinical descriptions), the overarching aim across all systematic case studies in psychotherapy is to study local and contingent processes, such as variations in patient symptoms and complexities of the clinical setting. The comprehensive framework approach will therefore allow reviewers to assess the degree of external validity in systematic case studies (Barkham & Mellor-Clark, 2003 ). Furthermore, assessing the case against its purpose will let reviewers determine whether the case achieves its set goals (research objectives and aims). The example below shows that Lunn et al.’s ( 2016 ) case is successful in functioning as a critical case as the authors provide relevant, high-quality information about their tested therapeutic conditions.

Finally, it is also possible to use CaSE to gather specific type of systematic case studies for one’s research, practice, training, etc. For example, a CaSE reviewer might want to identify as many descriptive case studies focusing on negative therapeutic relationships as possible for their clinical supervision. The reviewer will therefore only need to refer to CaSE questions in Table ​ Table13(2) 13 (2) on descriptive cases. If the reviewed cases do not align with the questions in Table ​ Table13(2), 13 (2), then they are not suitable for the CaSE reviewer who is looking for “know-how” knowledge and detailed clinical narratives.

Concluding comments

This paper introduces a novel Case Study Evaluation-tool (CaSE) for systematic case studies in psychotherapy. Unlike most appraisal tools in EBP, CaSE is positioned within purpose-oriented evaluation criteria, in line with the PBE paradigm. CaSE enables reviewers to assess what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). In order to explicate a purpose-based evaluative framework, six different systematic case study purposes in psychotherapy have been identified: representative cases (purpose: typicality), descriptive cases (purpose: particularity), unique cases (purpose: deviation), critical cases (purpose: falsification/confirmation), exploratory cases (purpose: hypothesis generation) and transferable cases (purpose: generalisability). Each case was linked with an existing epistemological network, such as Iwakabe and Gazzola’s ( 2009 ) work on case selection criteria for meta-synthesis. The framework approach includes core questions specific to each purpose-based case study (Table 13 (1–6)). The aim is to assess the external validity and effectiveness of each case study against its set out research objectives and aims. Reviewers are required to perform a comprehensive and open-ended data analysis, as shown in the example in Table ​ Table14 14 .

Along with CaSE Purpose - based Evaluative Framework (Table ​ (Table13), 13 ), the paper also developed CaSE Checklist for Essential Components in Systematic Case Studies (Table ​ (Table12). 12 ). The checklist approach is meant to aid reviewers in assessing the presence or absence of essential case study components, such as the rationale behind choosing the case study method and description of patient’s history. If essential components are missing in a systematic case study, then it may be implied that there is a lack of information, which in turn diminishes the evidential quality of the case. Following broader definitions of validity set out by Levitt et al. ( 2017 ) and Truijens et al. ( 2019 ), it could be argued that the checklist approach allows for the assessment of (non-quantitative) internal validity in systematic case studies: does the researcher provide sufficient information about the case study design, rationale, research objectives, epistemological/philosophical paradigms, assessment procedures, data analysis, etc., to account for their research conclusions?

It is important to note that this paper is set as an introduction to CaSE; by extension, it is also set as an introduction to research evaluation and appraisal processes for case study researchers in psychotherapy. As such, it was important to provide a step-by-step epistemological rationale and process behind the development of CaSE evaluative framework and checklist. However, this also means that further research needs to be conducted in order to develop the tool. While CaSE Purpose - based Evaluative Framework involves some of the core questions that pertain to the nature of all six purpose-based systematic case studies, there is a need to develop individual and comprehensive CaSE evaluative frameworks for each of the purpose-based systematic case studies in the future. This line of research is likely to enhance CaSE target audience: clinicians interested in reviewing highly particular clinical narratives will attend to descriptive case study appraisal frameworks; researchers working with qualitative meta-synthesis will find transferable case study appraisal frameworks most relevant to their work; while teachers on psychotherapy and counselling modules may seek out unique case study appraisal frameworks.

Furthermore, although CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose - based Evaluative Framework for Systematic Case Studies are presented in a comprehensive, detailed manner, with definitions and examples that would enable reviewers to have a good grasp of the appraisal process, it is likely that different reviewers may have different interpretations or ideas of what might be ‘substantial’ case study data. This, in part, is due to the methodologically pluralistic nature of the case study genre itself; what is relevant for one case study may not be relevant for another, and vice-versa. To aid with the review process, future research on CaSE should include a comprehensive paper on using the tool. This paper should involve evaluation examples with all six purpose-based systematic case studies, as well as a ‘search’ exercise (using CaSE to assess the relevance of case studies for one’s research, practice, training, etc.).

Finally, further research needs to be developed on how (and, indeed, whether) systematic case studies should be reviewed with specific ‘grades’ or ‘assessments’ that go beyond the qualitative examination in Table ​ Table14. 14 . This would be particularly significant for the processes of qualitative meta-synthesis and meta-analysis. These research developments will further enhance CaSE tool, and, in turn, enable psychotherapy researchers to appraise their findings within clear, purpose-based evaluative criteria appropriate for systematic case studies.

Acknowledgments

I would like to thank Prof Jochem Willemsen (Faculty of Psychology and Educational Sciences, Université catholique de Louvain-la-Neuve), Prof Wayne Martin (School of Philosophy and Art History, University of Essex), Dr Femke Truijens (Institute of Psychology, Erasmus University Rotterdam) and the reviewers of Psicologia: Reflexão e Crítica / Psychology : Research and Review for their feedback, insight and contributions to the manuscript.

Author’s contributions

GK is the sole author of the manuscript. The author(s) read and approved the final manuscript.

Arts and Humanities Research Council (AHRC) and Consortium for Humanities and the Arts South-East England (CHASE) Doctoral Training Partnership, Award Number [AH/L50 3861/1].

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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How to write counseling case studies

• Jan 31, 2021
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As a psychotherapy or counseling student, you are very likely to come across such written assignments as counseling case studies . As this is a very particular type of academic assignment, we created this guide to help you write psychotherapy case studies as a professional. 

A counseling case study is basically a simulation of your future work as a counselor. You have got a case about a person who has some psychological or mental challenges. You are provided with a description of the situation, the client’s complaints, behavior, some environmental factors like family, work, ethnic, cultural, and socio-economic factors, and you need to present your opinion about the situation and a tentative treatment plan. 

So essentially, you need to imagine yourself as a psychotherapist who works with this client and knows how to treat him. Therefore in your paper, you cannot just write irrelevant information such as definitions of mental diseases, history of counseling, or other side digressions just to fill up the required word count. This approach may work for many types of essays, but not for counseling case studies.  When writing case studies on psychotherapy, you need to be very on point. 

Your paper should contain three basic sections:

• Your analysis about the client’s situation;
• Diagnosis or summary/interpretation of the client’s problem from a particular theoretical standpoint or from an integrative perspective
• Interventions that might help the client based on your analysis. 

Your counseling case study should contain the analysis of the client's situation, assessment or diagnosis, and treatment plan containing proposed interventions and reflection on the therapeutic process. 

Keep in mind that the basic principle of academic paper writing is: KNOW WHAT YOU WRITE . That means know what you are required to write (make sure you understand the assignment and read the case carefully) and have the background knowledge about the theory and practice of psychotherapy, general counseling theories or a specific theory, and therapeutic techniques and interventions. 

For some people, such an assignment may seem overwhelming as you are not a working counselor yet and you are not sure how to tackle the client’s problem. But do not panic, just follow the steps below to produce a high-quality counseling case study. 

1.    Read your assignment and the case description carefully

Clarify all the terms you encounter in the case.  Make sure you know what theory of psychotherapy you are expected to follow in your diagnosis and treatment plan. If no theoretical approach is mentioned in your assignment, check if you have covered any particular theories in your classes.

If you are not sure what a theory of psychotherapy is, it’s a particular approach to interpret psychological and mental problems. The first theory of psychotherapy was psychoanalysis developed by Sigmund Freud. Its theoretical foundation relied on distinguishing three parts of the mind: ego, superego, and id; recognizing the role of the subconscious with its instincts and drives in psychological conflicts; interpreting maladaptive behavior through the lens of ego defenses; recognizing the role of early childhood experiences, particularly childhood traumas, in the pathophysiology of mental problems.  Later, many other theories of counseling were developed, such as Adlerian, existential, humanistic and person-centered, behavior (BT), cognitive-behavior therapy (CBT), Gestalt therapy, reality, feminist, narrative, solution-focused brief therapy, family systems therapy , and many others. So if earlier in the class, you covered humanistic counseling, you can use the humanistic theoretical approach in your case analysis (unless, of course, your assignment clearly states what theory you need to follow). 

2.    Review the textbook chapters on that theory paying attention to particular approaches to diagnosis and therapeutic techniques.

Theory is important as different theoretical frameworks interpret the same situation in a different way. For example, the same symptoms could be interpreted as defenses caused by childhood trauma in psychoanalysis, malfunctioning behavioral patterns in Behavior therapy, dysfunctional cognitive schemes in CBT, unfinished business in Gestalt, destructive environmental factors in feminist therapy, being stuck in a pattern of living a problem-saturated story in narrative therapy, and so on. 

3.    Re-read the case again paying attention to special terms

and see if you now understand the meaning of these terms after studying the literature. 

4.    Read additional resources (optional)

If you still have doubts about the case and how to proceed with it, you might need additional resources, either provided by your teacher or found on the Internet. If you have a specific psychotherapeutic theory to follow for your case, you can google “assessment and treatment in [your theory]” and search for books, worksheets, or articles. 

5.    Summarize the client’s situation in the case.

In this stage, we start writing up the draft of the case analysis. Describe the gist of the client’s problem as he sees it and as you can grasp from the description of his behavior, thoughts, and feelings in the case. If you can locate it in the case, summarize his family situation, relationships, the family of origins, and work relations . Also, note if any sociocultural factors, like race, religion, ethnicity, gender, income level, sexual orientation, or neighborhood , may have impacted the client and his significant relations. Note if the client has previously done efforts to deal with his problems and what these efforts were. 

6.    Formulate a diagnosis for the client.

This section will often require you to provide a diagnosis according to DSM diagnostic criteria or formulate a problem according to the conventions of your counseling theory. Some theoretical frameworks, like Narrative or Feminist therapy, do not make diagnoses in working with clients as they view clinical diagnosis as a pathologizing, discriminatory and condescending practice that skews power balance in favor of the therapist. So if you are writing the case study within one of these paradigms, you will not have to provide a diagnosis for the client. However, you will still have to make a sort of assessment. While diagnosis involves identifying specific mental disorders based on patterns of symptoms, for assessment , you need to point out the client’s main problem and identify the main factors of the client’s life that you think might be contributing to this problem.

If you need to provide the diagnosis according to DSM-V manual, pay attention to the Differential diagnosis section for each disorder description. If the client’s symptoms initially look like major depressive disorder, you can consult the differential diagnosis section in the major depressive disorder chapter to see if there are alternative explanations fitting the client’s symptoms. Thus, for major depressive disorder, the alternatives may be substance/medication-induced depressive or bipolar disorder, mood disorder due to another medical condition, ADHD, adjustment disorder with depressed mood, and sadness. Check the diagnostic criteria for all these disorders to find which one fits better. Some of the assignments will require you to spell out how many symptoms fit the criteria of the disorders, and name these symptoms.

7.    Outline the developmental context of the problem.

Write how the client’s problem developed over time. Consider if early childhood experiences, the family of origin, or family structure may have contributed to this problem. Has a similar problem been experienced by some family member before? Have environmental and socio-economic factors , like income level, race, ethnicity, religion, sex, sexual orientation, or any others, contributed to the development of the problem?  How do these developmental factors interact with the current stressors and conflicts to shape the client’s worldview? Does the client have social support or safety net to rely on? In some theoretical approaches, you will also have to identify the client’s pathogenic or irrational beliefs about himself (like BT and CBT), maladaptive styles of functioning (Gestalt, psychoanalysis), or internalized dysfunctional cultural narratives (narrative and feminist therapies). 

8.    Propose interventions and techniques that might benefit the client.

If you follow a specific theory, this assignment is not that hard. Just go to the textbook chapter of your theory, check the techniques and interventions, and choose the ones that are appropriate for your situation. But do not just mechanically copy the list of techniques from the textbook. Imagine yourself sitting with the client and having a counseling session with them. Where would you start? If you are at loss, remember that almost all theories start with establishing a contact, creating a therapeutic relationship with the client. You might start by explaining your role and responsibilities, the client’s rights and the process of therapy, and getting informed consent from the client. Listen to his story attentively and respectfully, learn reflective listening , suspend judgment about the client, show empathy . These are basic things that almost all therapists irrespective of their theoretical orientation and client’s problem, use. To these, you will add specific techniques from your theoretical approach or techniques that are normally used for similar problems. 

9.    Add reflections on the therapeutic process.

This section is not required in all case studies, but it’s often present since you need to be aware of this aspect as a future therapist. Here, write what you think about the client. Does she and her problems engage you emotionally? How might your feelings help or hinder the therapeutic process? Is there room for countertransference (when a client’s problem triggers an emotional response from you connected with your previous experience or your own problem). How might this client perceive you? How might her feelings help or hinder the therapeutic process? What challenges you might face while working with the client? What traits of your personality or any previous experience might help you establish trust and connection? 

Final thoughts

This is the general outline of all counseling case studies. The requirements might vary from case to case, but these steps are pretty much essential for a solid analysis of a client’s situation in a therapeutic setting. All these steps might seem overwhelming to you, but do not despair. To be successful, it is essential to understand the requirements and the case, have knowledge about your theory and counseling approach, and then use your brains to reflect on the given case using common sense, knowledge from the textbook, and your imagination of how you would work with a person presented in the case. As you see, in this paper there is not much room for paraphrasing or filling the space with irrelevant information. Everything must be very to the point. The only place where you can use some rewriting is the DSM diagnosis section, ONLY if the teacher asks you to note down all the symptoms that fit the diagnosis. Then you can take those symptoms from the diagnostic criteria of the disorder and slightly paraphrase them. The rest of the paper is your own reflection about the case, the client, and the ways to help him . If you feel intimidated, do not worry. Just start doing these cases, and you will get better with time. 

If you feel that you need professional help from a research assistant with good experience in counseling case studies, you’re at the right place. Check our prices for custom written counseling case studies and make your order here , it takes just a few minutes. 

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Person-Centered Therapy Case Study: Examples and Analysis

Introduction

Welcome to The Knowledge Nest's in-depth exploration of person-centered therapy case study examples and analysis. We aim to provide you with comprehensive insights into the therapeutic approach, techniques, and outcomes associated with person-centered counseling. Through real-life case scenarios, we demonstrate the effectiveness of this humanistic and client-centered approach in fostering personal growth and facilitating positive change.

Understanding Person-Centered Therapy

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a compassionate and empathetic therapeutic approach developed by the influential psychologist Carl Rogers. This person-centered approach recognizes the profound significance of the therapeutic relationship, placing the individual at the center of the therapeutic process.

Unlike traditional approaches that impose solutions or interpretations on clients, person-centered therapy emphasizes the innate human capacity to move towards growth and self-actualization. By providing a supportive and non-judgmental environment, therapists aim to enhance clients' self-awareness, self-acceptance, and self-discovery. This holistic approach has proven to be particularly effective in addressing a wide range of mental health concerns, empowering individuals to overcome challenges and achieve personal well-being.

Case Study Examples

Case study 1: overcoming social anxiety.

In this case study, we explore how person-centered therapy helped Sarah, a young woman struggling with severe social anxiety, regain her confidence and navigate social interactions. Through the establishment of a strong therapeutic alliance, her therapist cultivated a safe space for Sarah to explore her fears, challenge negative self-perceptions, and develop effective coping strategies. Through the person-centered approach, Sarah experienced significant improvements, enabling her to participate more actively in social situations and regain a sense of belonging.

Case Study 2: Healing from Trauma

John, a military veteran suffering from PTSD, found solace and healing through person-centered therapy. This case study delves into the profound transformation John experienced as he worked collaboratively with his therapist to process unresolved trauma. By providing unconditional positive regard, empathetic listening, and genuine empathy, the therapist created an environment where John felt safe to explore his traumatic experiences. With time, he was able to develop healthier coping mechanisms, embrace self-compassion, and rebuild a sense of purpose.

Case Study 3: Enhancing Self-Esteem

In this case study, we examine Lisa's journey towards building self-esteem and self-worth. Through person-centered therapy, her therapist empowered Lisa to identify and challenge deeply ingrained negative self-beliefs that inhibited her personal growth. By offering non-directive support, active listening, and reflective feedback, the therapist enabled Lisa to develop a more positive self-concept, fostering increased self-esteem, and self-empowerment.

Analysis of Person-Centered Therapy

The therapeutic relationship.

Person-centered therapy places profound importance on the therapeutic relationship as the foundation for positive change. The therapist cultivates an atmosphere of trust, respect, and authenticity, enabling the individual to feel heard and valued. By providing unconditional positive regard, therapists create a non-judgmental space where clients can freely explore their thoughts, emotions, and experiences.

Client-Centered Approach

The client-centered approach encourages individuals to take an active role in their therapeutic journey. The therapist acts as a facilitator, guiding clients towards self-discovery and personal growth. By allowing clients to set the agenda and directing the focus of sessions, the person-centered approach acknowledges the unique needs and perspectives of each individual.

Empowering Self-Awareness and Growth

Person-centered therapy seeks to unlock individuals' innate capacity for self-awareness and personal growth. Through empathic understanding, therapists support clients in gaining insight into their emotions, thoughts, and needs. This heightened self-awareness helps individuals develop healthier coping mechanisms, make meaningful choices, and move towards a more fulfilling life.

Person-centered therapy, as exemplified through the case studies presented, offers a powerful and transformative path towards holistic well-being and personal growth. The Knowledge Nest is committed to providing a platform for sharing knowledge, experiences, and resources related to person-centered counseling. Together, we strive to facilitate positive change, empower individuals, and create a more compassionate and understanding society.

Explore more case studies and resources on person-centered therapy at The Knowledge Nest to discover the profound impact of this therapeutic approach.

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Counselling Case Study: Working with Grief

Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of each stage will be different for each individual.

It is therefore understandable that an eclectic counselling approach to grief can be beneficial in allowing for the flexibility needed to work with individuals through various stages of the grief process. The following case study is a practical application of a variety of counselling approaches to one client and her experience of grief.

The client’s name is Joan. Joan sought counselling to deal with the unexpected loss of her daughter in a car accident. She received counselling about 2 weeks after her daughter’s death and continued with the counselling process over a period of 8 months.

The key features of Joan’s grief were her feelings of guilt and despair. In these areas, the counsellor worked mainly from a Person-Centered approach (PCT). The counsellor also utilised some techniques from Solution-Focussed Therapy (SFT) and Cognitive-Behaviour Therapy (CBT). A brief analysis of the case study and application of the various techniques are provided below.

Case Information

Joan is a semi-retired accountant, maintaining contract work with a few long-term clients to support herself in retirement. Joan is a divorcee, who lives on her own, in her family home. She is a mother of 2 children, Kirsten and Mathew, aged in their mid 20s. Joan has a supportive network of family and friends, including her sister, father, children, and friends from her gardening club.

Joan’s relatively steady life was overturned with the sudden death of her daughter, Kirsten. Kirsten was 24 when she died from head injuries caused during a car accident. She was admitted to hospital in a coma. Joan spent several anxious days with Kirsten, before she passed away.

In the days that followed, Joan arranged her daughter’s funeral and affairs and deferred her work commitments. Joan described this as a whirlwind period, where she operated in a mechanical way. She was completely absorbed in the organisation of Kirsten’s funeral and pushed aside her feelings of grief. Joan said that she found some security in the numbness that filled her during that time.

After a couple of weeks, however, Joan became concerned that she was not coping as she couldn’t move on from these feelings. People had commented that she should try to carry on as usual, however her numbness persisted and she couldn’t motivate herself to “carry on” as if nothing had happened.

Joan thought that there must have been something wrong with her and it was this fear that led her to counselling some weeks after her daughter’s funeral.

For ease of writing, the professional counsellor in this case will be referred to as “C”.

The Initial Stages

(Numbness) In the first session, Joan appeared somewhat vague and tired. She seemed focussed on describing the details of the funeral, the family members who attended and her concern about her daughter not having a will. “C” observed that Joan’s behaviour reflected a need to be in control of the situation and was a useful coping strategy for Joan at this time. “C” used PCT to build an empathetic understanding of Joan’s experience. She did not attempt to move Joan towards experiencing her grief, but trusted that Joan would reach this stage in her own time.

Joan began discussing the rapid way in which the whole event had occurred and the numbness that she was feeling. “C” used paraphrases and encouragers to assist Joan to express herself. “Everything has happened so quickly that you haven’t had time to absorb it all, is that right Joan?” “Yes”, Joan replied, “I’ve hardly had time to miss my little girl.” “You miss her,” responded “C”.

With this encourager, Joan began to cry and express her grief. Joan cried for some time whilst “C” sat with her in silence. At one point Joan apologised for her crying. “C” responded “It seems that you have a lot to cry about Joan. It shows me how much you loved your daughter.”

In the first session, Person-Centered therapy and Active Listening techniques enabled “C” to be guided by Joan’s readiness to express her feelings. The encouragers and reflection of feeling used, demonstrated to Joan that “C” understood her and allowed Joan to experience her feelings of grief, rather than to keep them at arms length.

Whilst “C” could have indicated to Joan that she was avoiding her grief, “C” instead trusted in Joan’s ability to express her grief in her own time. If Joan had not expressed her grief in this session, “C” would not have pressed the issue, although she may have encouraged Joan to have a further session within a few days.

(Grief and Despair) The following sessions were characterised by further experiences of grief and despair. Joan had found that her grief was no longer avoidable and her days were mostly filled with mourning. Joan abandoned her daily routines such as grooming, making meals and other basic self-care practices.

Joan’s disheveled appearance at the counselling sessions were concerning. At this point, “C” became more directive and suggested that Joan might have someone live-in with her for a while. Whilst “C” was encouraged by Joan’s regular adherence to the counselling sessions, she felt that Joan may need some extra support at home.

Joan contacted her sister Kerrie, who was available to stay with her for a month. Kerrie proved to be good support for Joan and provided her with gentle, yet insistent encouragement to face the everyday challenges.

Over several weeks of counselling, Joan had moved further into stages of despair and guilt. She described her life as being swallowed by a black hole and felt that she would never get over her daughter’s death. She felt that every day dragged by with no release from the pain. She had difficulty getting out of her bed in the morning and was constantly tired from lack of solid sleep.

“C” continued to employ PCT to allow Joan to explore and express her feelings and thoughts about her daughter’s death. Joan focussed heavily on her pain and seemed to stay with these feelings for a long time. “C” observed that Joan’s thoughts did not seem to be focused; she quickly moved from one topic to the next. “C” used summarising skills to help Joan highlight the key recurring issues from her thoughts.

“C” continued to trust that Joan would move through her feelings of grief in her own time. “C” did however experience some frustration with Joan’s continual despair. “C” sought the counsel of a colleague, who advised her to maintain her faith in Joan’s ability to grow and heal and reminded “C” of how the resolution of grief can often be a long-term process. The colleague also suggested some role-play techniques that “C” could use to work on Joan’s experience of her feelings.

(Guilt) Guilty feelings about her inability to prevent her daughter’s death were also of concern for Joan. “C” avoided telling Joan that she was not responsible for Kirsten’s car accident, and encouraged Joan to explore her guilt. In many instances grieving people feel guilt in relation to their loss. Often they will be told that they are not at fault, by well meaning people. The concern for counsellors is that grieving people are feeling guilty and will benefit more from expressing their guilt.

Dismissing guilty feelings won’t stop the grieving person from feeling blame and may lead to the increase of these feelings. “C” realised that Joan’s guilt was a means of expressing how fervently she wished to have her daughter with her still. “C” invited Joan to express her sorrow and guilt to Kirsten in a role play activity.

Afterwards, “C” encouraged Joan to debrief and talk about the effect of the activity. Joan was able to acknowledge the depth of her love and concern for Kirsten. “C” supported Joan by offering encouraging feedback. “C” was particularly taken with the extent of love and devotion that Joan displayed towards her daughter.

Joan left the session a little lighter for the experience. She said that she had been able to release some of her guilt and that she felt her despair ease a little. After two months of counselling, both Joan and “C” recognised this as a small breakthrough of acceptance.

Middle Stages

Joan’s grief and despair continued into the middle phase of the counselling sessions. Her emotions came in waves, rather than the constant fog of despair that had characterised her earlier sessions. “C” was continuing to utilise PCT with Joan to explore her issues. Joan expressed a readiness to establish goals during this stage. “C” implemented some CBT techniques for this purpose.

(Feelings of Panic) Kerrie had been encouraging Joan to take on small, everyday tasks such as walking to the shops, or posting the mail, in order to get out of the house for a while. Joan said she had done these tasks reluctantly as she was concerned about trying to “put on a brave face” in public.

Joan related a particular incident where she was at the local shop. She explained that when picking items from the shelves, she had selected her daughter’s favourite brand of biscuits. Feelings of panic had come over her as she realised that she no longer needed to buy the item, but she couldn’t bring herself to return the item to the shelf. In this state, she left all her purchases in the shop and walked straight home.

This incident had increased Joan’s anxiety about her ability to cope and accept her daughter’s death. In the session, “C” validated Joan’s experiences as being normal and a legitimate part of her grieving. As a part of the CBT process, “C” clarified and identified the causes and effects of Joan’s feelings of panic. These were as follows:

A realisation that her daughter was absent in her everyday life A rejection of awareness that her daughter was absent in her everyday life Conflicting emotions about acceptance of daughter’s absence

• Causing anxiety
• Causing a belief that she will never be able to accept her daughter’s loss
• Causing a fear of losing control in public places

“C” and Joan discussed the nature of the anxious feelings, and Joan’s associated beliefs and fears. Together they devised a number of goals, including (1) the development of new beliefs, (2) relaxation and (3) taking it one step at a time – otherwise referred to as a graded-task assignment.

Joan’s new beliefs included:

• It is normal to want my daughter back
• I am normal to grieve for and miss my daughter
• It doesn’t matter if I cry in public
• Time will help me to heal

She kept notes in a personal journal about when she used these new beliefs. The journal writing was also a process that allowed her to identify other problematic beliefs and thoughts. Once identified, she developed more appropriate and accepting beliefs.

In preparation of taking it one step at a time, Joan and “C” devised some relaxation techniques for Joan to use when she felt a sudden onset of panicky or anxious emotions. Joan had used imagery before and found that an effective method of relaxation. Joan was to imagine a warm, white light surrounding her whenever she felt even slightly anxious. They also devised some imagery to help Joan continue to experience the overwhelming nature of her grief.

Joan often referred to her feelings as a fog, and so “C” encouraged her to imagine sitting in a fog, which was black, thick and impenetrable. Little by little, she suggested that Joan should try to make the fog thin out with her mind. (It is important to note that this imagery was to be used at times when Joan felt bogged down in despair, but not during her anxious moments).

Joan was to record her practice of her relaxing imagery (white light) and to note her responses to the technique. She also recorded the times she used her despairing imagery (black fog) and the extent to which she was able to thin the fog with her mind. The purpose of the exercise was to increase her relaxation and to give her an image of her despair and a means to control it as time went on.

The ‘one step at a time’ goal consisted of Joan taking small steps towards running errands and taking on more of her everyday responsibilities. Her tasks involved the following:

• Plan meals for week
• Write a grocery list
• Go shopping with Kerrie.

Using her relaxation imagery, Joan completed the following graded tasks:

• Imagine walking around the shops
• Drive with Kerrie to the shop and stay in the car
• Walk with Kerrie to the shop door
• Walk with Kerrie around the shop for 10 minutes approximately
• Start to purchase a small number of items
• Complete an entire grocery shopping task

Each week, Joan completed a harder task. It took her only 4 weeks to complete a full shopping trip, although she experienced several occasions of feeling overwhelmed. Each time this occurred she gripped the shopping trolley and imagined the white light. Kerrie encouraged her to breathe deeply and relax. A couple of times, they left the shop (abandoned the trolley) when Joan felt she could not cope. They came back the following day to complete the shopping.

The important thing for Joan was to accept the times when she could not cope. Kerrie proved to be a supportive role model for Joan, helping her to accept her reduced ability to cope by offering encouraging comments and faith that Joan would heal.

Joan applied the graded-task technique to other areas of her life. “C” observed Joan’s increasing attention to self-care and other routines of everyday living.

Final Stages

(Acceptance) Joan’s increasing acceptance of the loss of Kirsten became more obvious with the passing of time. By dealing thoroughly with her despair and grief, she naturally moved on with her life and mourned less and less. After six months, the rewards for both “C” and Joan were evident in her long term improvement and growth.

Joan’s ability to develop goals for herself was greatly improved, as was her motivation. Joan was living independently again and without Kerrie around, she took on more responsibility and began to make plans for her life without Kirsten. Joan’s plans included a number of support mechanisms, as well as long-term goals for herself.

Joan had taken to visiting her daughter’s grave on a monthly basis. During her intense despair, she had been unwilling to venture to the cemetary. Due to her increasing acceptance, she was more inclined to visit and found the visits to be a sad, yet calming experience. The visits allowed her the opportunity to tell Kirsten the things she had left unsaid, and to update her daughter about her life, as she would have when Kirsten was alive. Joan found the visits kept Kirsten’s spirit and memory alive within her.

In these stages, “C” continued using PCT, and incorporated SFT to assist Joan to define her goals. “C” complemented Joan on her inventive ways of honoring her daughter’s memory. “C” was encouraged to see that Joan was actively seeking personal ways to express her grief.

Together, they worked to build Joan’s miracle picture. Joan expressed an interest to honor Kirsten’s life, by writing a book. Joan wanted to combine her own and Kirsten’s journals to recount the significance of her life and death. The process would also be a means to resolve her grief and offer a parting gift to her daughter.

Joan’s miracle picture included redefining her life goals to determine what was important for her. Kirsten’s death, whilst painful, had also brought growth and changes with it, and Joan was increasingly inclined to shed parts of her life that no longer held meaning for her. She threw out material things such as old furniture, files and boxes of junk and mentally discarded the maintenance of acquaintances that she no longer felt obliged to remain in contact with.

She renewed her bonds with close friends and family. Kirsten’s death allowed her family to grow closer to one another. Joan was buoyed by the love and support of these few, special people during her long months of despair.

Joan accepted that she would never completely ‘get over’ Kirsten’s death and that that was okay. Counselling assisted her to realise that her daughter would remain a part of her forever. She made a pledge to herself that she would continue to learn ways to live with Kirsten’s absence. Her journal writings and the possibility of publishing a book for Kirsten, would provide her with some therapeutic means of coping and expressing her grief. Joan would also draw from the support of her family and friends in times of need, particularly around the times of Kirsten’s birthday and the anniversary of her death.

End of Session

The case study has illustrated some of the stages that clients may experience due to the loss of a loved one. It has also attempted to demonstrate the way in which PCT lent itself to the complex and individual experience of Joan. The key issue from the PCT perspective was “C’s” respect for Joan to grieve and grow to acceptance in her own way and time.

CBT was applied to changing Joan’s negative thoughts about her ability to cope with her daughter’s loss and the fear of losing control of her emotions in public places. The imagery was a technique that Joan had prior experience with and was therefore ideal for her. Another client, may prefer other relaxation methods. It is important to identify strategies that the client is comfortable with.

Graded task assignments, journal writing, role plays, homework and other practical strategies such as developing support networks are also invaluable CBT techniques. Timing is important when introducing strategies, and the client should not be pushed into solutions before they are ready to accept them. Wherever possible, the counsellor should consult with the client about their ideas for, and their suitability to, particular techniques.

Once the client is ready to focus on solutions to their problems, SFT can be an invaluable tool for identifying the client’s goals through development of the miracle picture. The use of SFT has been briefly presented in the case of Joan, to illustrate its effectiveness in drawing out the plans and goals that Joan aspired to.

Author: Jane Barry

Related Case Studies: A Case of Grief and Loss ,  A Person Centred Approach to Grief and Loss , A Case of Acceptance and Letting Go

• March 15, 2007
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• Case Study , CBT , Person-centred , Solution-focused
• Case Studies , Loss & Grief

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Couple Cases

Below you’ll find case studies of real clients that have attended couple’s counselling at All in the Family Counselling with our professional trained marriage expat counsellor. These cases do not represent all cases seen at our centre but rather are intended to give you insight into what makes for successful outcomes and the time and effort the clients choose to put in to make their relationship change. Each couple’s relationship is unique and has its own history which our therapist will attend to. But we hope you will find it helpful to see what successful clients choose to do and their outcomes.

Case Study 1

Profile : Professional couple married for 6 years but known each other for 10 years. The couple is in their early 30s.

Reason for Counselling : Couple came into counselling because of husband’s excessive use of pornography, a reduced sexual life and overall lower intimacy in the relationship. Wife was prepared to file for divorce if things didn’t improve rapidly. Wife had loss of trust due to pornography use.

Number of Sessions:   Couple had a total of 4 sessions with husband attending to 2 individual sessions. At the client’s initial session everyone agreed to the problem and what a positive marriage would look like for them.  They were taught basic relationship skills and given homework to practice. At their 2 nd  session, which was 10 days later, we reviewed their homework and both individuals had great revelations about themselves, each other and the relationship. They were taught additional relationship skills and given more homework to practice for 14 days.  The 3 rd  session we reviewed homework and refined skills and integrated new relationship concepts into the relationship including negotiating win-win for the relationship and managing perceptions in communication. Final session was 30 days later in which we reviewed their homework, revised some of their skills and gave them a framework to help identify and remedy problems if they were heading back into old relationship habits.

Success Factors:   This is an unusual case for a couple in crises to come to counselling and so dramatically turn their relationship around. The reason the couple experienced such dramatic success was that they had come into counselling early once the issue of intimacy and pornography were discovered. This couple was also highly motived to make counselling work and they energetically completed their homework in between sessions. The couple also had a lot of positive regard for each other and good personal insight into themselves and each other. The husband also attended a couple of individual sessions to work on stress management.

Case Study 2

Profile : Couple married for over 10 years in their mid 30s. Both have a college education and are professionally employed. Couple has no children.

Reason for Counselling : Counselling was initiated by the wife who had found out only 4 days prior to contacting our agency that her husband had an affair and both of them wanted to repair and improve the relationship.

Number of Sessions:   Couple had a total of 6 sessions over 3 months.  The first session was getting agreement that both couples wanted to repair and improve the relationship. Both parties agreed to not introduce punishment into the relationship as a result of the affair. The couples were given some new basic relationship skills and given homework to complete in between session including not discussing the affair.  Session 2 was 10 days later and the focus was on building a unified goal for the relationship. Four goals for the relationship were mutually identified and agreed to. Couples were given more relationship skills and homework to practice. The next 3 sessions were spread out over 2 months and focused on relationship skills that targeted communications, perceptions and internal control all with the couple doing homework in between sessions. The final session the clients evaluated how they did meeting their goals and they felt they got about 70–85% of each of their goals which was satisfactory for them. They felt confident with their new relationship skills. Trust had been restored, forgiveness was given and communication dramatically improved and the couple was established in their new and improved relationship behaviours.

Success Factors:   Couple came in quickly after finding out about the relationship. Both individuals in the relationship agreed to not introduce punishment into the relationship. This couple was focused on the present and building the future relationship.  The incident and issues of the past were only used as guidelines to help us know what worked and did not work. The couple was highly motivated to repair and improve their relationship and would complete their homework and came prepared to fully engage during the counselling sessions.

Case Study 3

Profile : Professional couple married for 7 years. The couple is in their late 30s. Had a history of infertility and infertility treatments that resulted in 2 children in last 3 years prior to treatment.

Reason for Counselling : Couple came into counselling because of dramatically reduced intimacy, increased fighting, difficulty communicating and negative perceptions of each other’s behaviours.

Number of Sessions:   Couple had a total of 12 sessions with each client engaging in 2 individual sessions within 5 months. The first session focused on stabilizing the relationship and providing them with basic relationship skills. The homework started to focus the couple on building positive regard towards each other.  Then next 2 sessions were focused on developing a new relationship base from which to make all decisions-shifting it away from the children as the base and back to the couple.  The next 4 sessions included reviewing the homework the clients were completing in between sessions, the lessons and observations they were learning as well as modifying and enhancing basic communication skills that included perception taking, learning to negotiate a win–win for the relationship and continuing to build positive regard.  The individual sessions were focused on personal issues that were affecting the relationship.  Individual sessions addressed some of the loss and trauma related to infertility treatments and stress and anxiety management.

Complicating & Success Factors:   This couple had a more complex prolonged history of infertility, stress and trauma that went on for a couple of years prior to entering counselling resulting in a more negative view of each other that reduced trust and positive regard for each other. This increased the number of sessions for the couple and individuals session were recommended.

However, the couple still had enough positive regard for each other and was committed to the counselling process because they really valued what they had earlier in their relationship. While the couple experienced some setbacks initially and was slower to implement their new relationship skills than the previous couples, they managed to keep coming to counselling and do most of the work.  As they start the client was successful because they gave counselling enough time to work and practice their new skills and continue to get feedback and guidance while working both on their relationship issues and individual issues. This couple needed more sessions because there were complicating factors and the issues had been developing for a longer period before coming for help.

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Counseling Case Report

Counseling psychology, table of contents, bio data                                                                                                                    .

Age: 13 Years

Gender: Male

Education: 6 th grade

No. of Siblings: 5 sisters

Birth Order: Middle born

Religion: Islam

Informant: Father

Date of Referral: Feb 09, 2017

Reason for Referral

The client was taken from the PSRD and referred to trainee psychologist. Already the client was under the treatment of psychiatrist and a physician and referred to counselor for psychological assessment and management.

Presenting Complaints

According to client.

The client reported that following symptoms were present

I am Always sad. (six months)

I get very angry whenever I’m not able to do my own work. (six months)

Children make my fun when they see m hand in the school. (six months)

I don’t want to go out of the home because everyone watches me weirdly. (four months)

According to Informant (Father)

The informant reported that following symptoms were present in client

Most of the rimes he remains sad. (six months)

He gets very angry as compared before. (six months)

He feels that everyone make fun of his hand. He goes outside the house for lesser time. (six months)

He has become weak in education. (three months)

His sleep time is very short. (six months)

History of Present Illness

The client was taken from PSRD with complaints of sadness, anger, sleep disturbances, poor academics and low self-esteem. The client had an accident eight months before a bike hit him as he was crossing the road. When the client was taken to hospital his hand was completely damaged and doctors had to amputee his hand. He was discharged from hospital after two week and his wounds were recovered after three months but he sometimes felt phantom limb pain in the area where the limb was amputee.  The client continued his school after 3 and half months of his injury as he was recovered now but his hand was amputee which was the cause of distress for him. The client was feeling depress on losing his hand as it was badly effecting his body image. The client felt humiliated when his school fellows made fun of his amputee hand. The client was angry that why this accident was happened to him. The client was very upset that he was not able to do his work by himself. He was worried that his family was not financially strong they were not able to spend enormously for the treatment as artificial hand for their child so it will be helpful for him to perform his daily tasks. The client was uncomfortable while facing other people according to him they looked at him in a strange way.

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Family History

The client belonged to middle class family. The client lived in a joint family system with his parents, his Uncle and aunts. His father A.M was 35 years old and driving an Auto Rakshaw. The client had a satisfactory relationship with his father. According to client his father was very religious and also takes him to mosque at the time of prayers. His father always taught him to differentiate between right and wrong. His father helped him in his studies and had not allowed him to take tuition instead he personally sits with him to get his problems solved. He also played with him in his leisure time. His father played cricket and football with him on Sunday. His father tries his best to keep their family happy. His father worked hard to make money for their family. According to client his father loved him a lot and always tried to cheer him up when he was in sad mood. His father always taught him good values and not spoiled him by bought him all the things that he wanted. The client had a very good relationship with his father as he discussed everything with him without hesitation.

The client’s mother was N.A and she was 30 years old. She was a housewife. The client had satisfactory relationship with his mother. He can talk to her about his problems he had in his life and in school. He talked to her because she listened him and gave good advises to him. His mother cooked his favorite food for him when he came home from school. His mother was very caring and loving and helped him in doing his homework. According to client her mother taught him how to eat healthy food and dress himself, to how to react to the situation. His mother taught him little things as how to tie his shoes and to be polite and respectful to adults. The relationship of client’s parents was satisfactory as they have mutual understanding.

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He had three sisters one was 16, 15 years old and youngest one was 7 years old and his brother was 5 years old. He had a satisfactory relationship with them. He played with them in his free time. He also quarreled with them during playing. He had also very good relationship with his cousins, uncle and aunt. They loved him very much because he was the first born child at their home. They always cared him and taught him good manners. The client was very obedient of his parents and uncles and aunts. The home environment of client was very good all the problems were solved by mutual discussions.

Personal History

Birth and early development.

According to client’s mother client was born in hospital and his birth was normal. All the developmental milestones were reported to be achieved at appropriate age. No neurotic traits were reported. The client was very healthy at the time of birth. The client started sitting with the help of support at the age of approximately 5 month and started standing at the age of 9 month. According to informant the client had some problem in speech and started complete talking at the age of approximately 3-4 years. The client had not any problem in eating and started eating solid food at the age of approximately 5 month. The client had normal sleep patterns in his childhood. His mother did not face any problem during pregnancy or at the time of birth. No history of smoking or alcohol use was present.  There were no prenatal or postnatal complications reported. No physiological illness, psychiatric disorder or major injury was reported in the client.

Educational History

The client started his studies the age of 5 years. As his father reported that he was a very bright student in his class he always got good grades in all subjects. Mathematics was his favorite subjects. But after that incident he mostly missed his classes because he felt humiliated when his class fellows made fun of his hand and that’s why his academic performance decreases with time. His parents and teachers paid full attention on him and helped him in studies. At home he studied under the supervision of his parents.

Informal Academic Assessment

• Reading: He said that I could read well Urdu and English.
• Writing: He could write comfortably in Urdu and English well according to his class.
• Mathematics: He is quite good in Mathematics.
• English: Client has bit difficulty in speaking and writing English.
• Urdu: He could speak and write Urdu good as well.

Social History

The client was friendly in nature and had many friends in his school. He played with his friends in his free time. He liked to play cricket and football with his father on Sunday.  He usually play with his cousins. He liked to watch cartoon of tom & jerry with his siblings and cousins. The client was very helping at his home.he helped his grandmother and paternal aunt in doing house chores. The client had satisfactory relationship with his siblings and family members. After that incident he mostly spent his time at home and did not play with his friends outside the home. He had three close friends in schools and played with them in the break time.

Pre morbid Personality

The client was very friendly and happy before this accident. The client was very lively and enjoyed every moment of his life now he remained sad for a long period of time. The client had very calm personality before this accident now he became angry on small things and started fighting with his family members. The client was a very hardworking and brilliant student. The client liked to participate in sports and games. He had many friends in his school. The client was a shy person and did not talk too much with strangers. He was very helpful in nature and helped his grandmother, Uncles and aunts.

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Psychological Assessment

The psychological assessment was carried out at two different level

• Informal psychological assessment
• Formal psychological assessment.

The informal assessment included mental state examination, symptom checklist and formal assessment included Child Depression Inventory (CDI), The Self Image Profile (SIP-C) and The Adolescent Anger Rating Scale (AARS).

Informal Assessment

Mental state examination ., general appearance and behavior.

The client was well and season appropriate dressed. He 13 years old boy with average height. He seemed to be fragile and weak apparently. His shoes was neat and clean. He combed his hair well. His eye contact was frequent He was not comfortable at first but when confidentiality was assured he easily explained all issues. He kept his hands and legs in a comfortable posture throughout the sitting.

Speech and Thought

His content of speech was adequate and understandable with appropriate answering of all questions. Progression of speech was quite slow.He was logical and meaningful. His speaking was in an organized way. He was frequently speak Urdu.  

He spoke in average and serious tone, his volume was quite low and his speech was comprehensive.

Client’s thought process was quite inadequate. As following questions were asked to the client.

Client reported that he do not know why he get angry on certain things without any reason.

He said that he has been living a purposeless life. Which has no direction. Client’s answers showed that he has inadequate thought content.

Language Assessment

Receptive speech.

  The client’s receptive speech seemed to be good. It was relevant.

He could easily tell the meaning of home, sky and balloon.

He could easily identified his right left parts very well.

Mah – Tuh – Suh-  Puh

He was able to recognize information well.

Expressive Speech

The client’s expressive speech seemed to be Excellent. Although at starting of assessment he was hesitant but after some motivation it seemed that he had no difficulty in expressing himself in speech.

Sp (as a spot), PL (as a play), Th (as a thing)

Mood and Affect

Objective  The client seemed to be with fine mood. His mood got low at explanation of his accident.

Subjective  He reported that he is in fine mood was comfortable in sitting.

Affect  Client’s affect was appropriate to the situation.

Range His affect was restricted did not show high emotions.

Intensity Client’s intensity was flat.

Quality He was sad and after sometime he became anxious.

Visual Perception

                        The client’s visual perception seemed to be adequate.  He can easily read and understand the things. He can easily read all the formal tests provided him.  

Auditory Perception

He was having an excellent auditory perception. He was able to understand the instructions given to him and could hear the questions easily. He could easily differentiate between the sounds of people around. He could understand the conversation indicating well auditory perception.

Motor Assessment

Gross motor assessment.

                        Client’s gross motor activities seemed to be fine. He could walk, run and climb stairs easily and did not find any difficulty to handle these skills.

Fine Motor Assessment

                        Client’s fine motor activities also seemed to be fine. He is right handed. He was able to hold pencil the correct way. He can cut things, use scissors properly with other hand.

Cognitive Assessment

General fund of knowledge.

The client seemed to be having good general fund of knowledge. He responded to questions correctly. Following questions were asked by the client to access the general fund of knowledge.

1: What is capital of Pakistan?

Ans: Islamabad

2: Who is the poet of Pakistan?

Ans: Allama Iqbal

3: When do we celebrate Independence Day?

Ans: 14 th august

He was easily answered all these questions.

Abstract Reasoning

The client’s abstract reasoning seemed to be average. He could easily explain the similarities and differences between things e.g book and laptop, Tiger and Leopard.

But he did not answered the difficult. Like   

                        The client’s vocabulary of English was quite below average as he was not able to spell communication, celebrity, generation, but the vocabulary of Urdu was better as compare to English. As he tell the correct meaning of Urdu word.  

Attention and Concentration

             The Clients attention and concentration seemed to be above average. He remained attentive during the sessions and answered to questions attentively and also showed high interest in attempting psychological tests.  

Short Term Memory

                        The client’s short term memory was good . He was able to recall things properly. He could memorize the name of his institute and his teacher’s name. Which dress he had worn yesterday.

Long Term Memory

                        The client’s long term memory was also above average. He can recall his address, his date of birth. He was able to memorize his early school days. He also memorized the incidents concerning to his past life.

Orientation

The orientation of time place person was accurate. He could report the time exactly. As some questions were asked what is day today? What is date today? How would you describes this situation? He knew the persons around well, also was well aware of the place he was living in. He easily answered all the questions.

Insight and Judgment

The client had well developed insight of his problem. He knew his responsibilities, he knew that studies is essential part of life. So, he worried about his studies. As some questions were asked by him

Symptoms Ratings

The ratings of the symptoms of the client were taken from both the client and the informant who was his father in this case. These ratings were made out of 10 in the increasing order of the severity.

The client’s and the informant’s ratings of the symptoms from 0 – 10 in order of the severity

  Symptoms                            Client’s ratings                Informant’s ratings                         Mean

Sleep disturbances                              8                                              9                                                  8.5

Depression                                          7                                              8                                                    7.5

Self image                                           8                                              8                                                       8

Anger                                                  8                                              9                                                     8.5

___________________________________________________________________________

Formal Psychological Assessment

As the client was very cooperative and motivated to take part in the session. After taking his consent to complete the tests relevant to his problem they were filled by him as the tests were too long so client was able to complete them in two settings. Formal assessment was done with the help of standardized tests and inventories which are described as follows:

Child Depression Inventory (CDI)

The self image profiles for children (sip-c) and adolescents (sip-a).

• The Adolescent Anger Rating Scale (AARS )

The Child Depression Inventory (CDI) is a symptom-oriented instrument for assessing depression in children between the ages of seven and 17 years. The basic CDI consists of 27 items, but a 10-item short form is also available for use as a screener. The CDI was first published by Maria Kovacs in 1992. It was developed because depression in young children is often difficult to diagnose, and also because depression was regarded as an adult disorder until the 1970 (kuvacs,1992).

Test Administration

Child Depression Inventory (CDI)was administered on the client on Thursday, May 5, 2015, in a well and ventilated room of the hospital. The client was sitting on a chair, behind the table and the instructions were given to him according to the manual. The difficult items or their responses were repeated again for his convenience when he asked for, so that he could comprehend the test easily. He took her 10 minutes to complete the test.

Quantitative Analysis

Table 1. The client’s total raw score, range and remark on CDI

Qualitative Analysis

The client completed the CDI in ten minutes and obtained the raw score of 05 which means that his t-score was 56 which suggests slightly above average depression. The CDI was able to screen out slightly above average depression in the client. The CDI was able to screen out depression in the client. The results of the test applied on the client placed him among the category of slightly above average depressed children individuals. His results are consistent with the symptoms he was experiencing.

The Butler Self Image Profiles (SIP) is brief self-report measures that provide a visual display of both self-image and self-esteem. There are two forms; the SIP-C for children aged 7-11 years and the SIP-A for adolescents aged 12-16 years. Both of the forms have different item content appropriate for respective age levels, but an identical format and scoring procedure. The SIP taps the individual’s theory of self. Both the SIP-C and SIP-A consists of familiar self-descriptions; 12 of a positive nature, 12 with a negative slant and one neutral item. All self-descriptions are words or short statements generated by children and adolescents (Butler, 2001).

The Beck Depression Inventory (BDI)administered on the client on, march, 2017, in a well-lit and ventilated room of the hospital. The room was peaceful and noise free and there was not any distraction. It was not crowded and the client was made to sit in a comfortable chair with a desk in front of it, placed on one side of the room. The client was sitting on a chair, behind the table and the instructions were given to him according to the manual. The client was provided with a copy of the Beck Depression Inventory, so that she could follow along and was asked to report his feelings for the past two weeks, including today. He 5 minutes to complete the test.

Quantitative analysis

 Table 1 . The scores of The Self-Image Profile

The client obtained a raw score of positive self-image 33 which was lower than the cut off score which indicated that the client low positive self-image and it was a matter of concern. The raw score of negative self-image was 52 which were equal to the cut off scores and it depicted that the client had high negative self-image. The raw score of self-esteem was 87 demonstrated that the self-esteem of client was very low and it was matter of concern. The high score of self-esteem scale reflect significant difference between “what I am”, “what I like to be” and thus is indicative of low self-esteem. This score may indicate that how much the subject does not like what already he is Self-Image Profile was able to screen out positive self-image toward oneself, negative feeling toward one’s own self and self-esteem of one’s self. These results are consistent with his background as the client was taken from the hospital with low self-esteem.

The Adolescent Anger Rating Scale (AARS)

The adolescent anger rating scale (APS) was designed to help clinician’s asses several aspect of anger, total anger, specific type of anger (i.e., instrumental anger and reactive anger) and anger control in adolescent ages 11 to 19. The AARP is appropriate for use in clinical settings as both a screening measure for social maladjustment behaviors and as a measure of treatment affects. In school setting, the AAPR provides an efficient and economic screening, instrument for adolescents who demonstrate anger pattern that are potentially harmful to themselves or others (Deanna,2000)

The adolescent anger rating scale (AARS) was administered on the client on Thursday, May 5, 2015, in a well lit and ventilated room of the hospital. The room was peaceful and noise free and there was no distraction. The client was made to sit comfortably in his bed. The instructions were given to him according to the manual. The test was orally administered to the client. The client was provided with a copy of the (AARS), so that he could follow along. The difficult items or their responses were repeated again for his convenience when he asked for, so that he could comprehend the test easily. He took 20 minutes to complete the test.

The client obtained the raw score of 90 which t score was 55 and percentile was 73. The results of the test showed that client had average level of anger.

Summary of Psychological Assessment

The client’s scores on child depression inventory showed that he had slightly above average depression. According to the scores on self image profile for children showed that he had low positive self image, high negative self image and low self esteem. The scores on adolescent anger scale showed that client had average level of anger.

Identification of Problem

The client was taken from the Jinnah Hospital with complaints of sadness, anger, sleep disturbances, poor academics and low self esteem. The client had an accident eight months before as his left hand was seriously injured by chaff cutter machine. When the client was taken to hospital his hand was completely damaged and doctors had to amputee his hand. The client was feeling depress on losing his hand as it was badly effecting his body image. The client felt humiliated when his school fellows made fun of his amputee hand. The client was angry that why this accident was happened to him. The client was very upset that he was not able to do his work by himself.

Case Formulation

The client was taken from the hospital with the problem with his hand. His hand was completely damaged in that accident and doctors had to amputee his hand. The client worried and depress about his condition because he had to face difficulty in his daily life activities. The psychological assessment was carried out on informal as well as formal level. The informal assessment included mental state examination and formal assessment included Child Depression Inventory (CDI), The Self Image Profile (SIP-C) and The Adolescent Anger Rating Scale (AARS). The results of the tests indicated that client had slightly above average depression, had low level of positive self image and high negative self image and average level of anger,

The word amputation is derived from the Latin amputare, “to cut away”, from ambi- (“about”, “around”) and putare (“to prune”). Amputation is the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger. There are many reasons an amputation may be necessary. The most common is poor circulation because of damage or narrowing of the arteries, called peripheral arterial disease. Other causes for amputation may include: severe injury (from a vehicle accident or serious burn, for example), cancerous tumor in the bone or muscle of the limb and serious infection that does not get better with antibiotics or other treatment etc (McNaughty, 2015). In clients case he was seriously injured by the chaff cutter machine and when he was taken to hospital there was poor circulation of blood in hand and doctors had to amputee his hand.

Most patients who lose a limb as a result of traumatic or surgical procedures encounter a series of complex psychological responses (Cansever et al 2003). Many people successfully use these responses to adjust to amputation, but others develop psychiatric symptoms (Frank et al 1984). Shula and colleagues (1982) and Frierson and Lippmann (1987) note that as many as 50% of all amputees require some sort of psychological intervention, and Shula and colleagues (1982) reported that depression is the most common psychological reaction among amputees. The client was feeling depress on his condition because he had lost his body part and he was not able to perform his tasks easily by himself.

According to research by Kindon and Pearce (1982), Kohl (1984), and Cansever and colleagues (2003), psychological reactions to amputation depend on a number of factors, which include age and sex, type and level of amputation, lifelong patterns of coping with stress, value placed on the lost limb, and expectations from the rehabilitation program. Kohl (1984) added that the individuals affected by the traumatic loss of a limb are required to face a redefined body and self as well as a new reality. The client had to face problem regarding his self image as the client was in the age of pre adolescence but children adapt well to the loss of function and manipulate prostheses and other limbs with great agility. They are particularly sensitive to peer acceptance and rejection. The client was also worried that how he will participate in physical activities that required both hands as cricket etc.

The loss of limb through accident is a tremendous shock. Unless your child is very young, they will feel the same emotions as adult amputees – grief, depression and anger. In addition, children often feel guilt for bringing pain and problems to their parents (Ratto, 2014). In client’s case he was very angry that why that accident was happened to him and it caused problems for him and his family.

Management Plan

Management plan is designed to help the client to resolve his problems and to return his back to the community sound and healthy. Several therapeutic interventions are designed for this purpose to be used with the client. Some of the therapies that can be used for the client who is suffering from depression, problems of anger and negative self-image are as follows

Supportive work

Psycho education.

• Behavior Therapy
• Cognitive Behavior Therapy

Rational Emotive Behavior Therapy

Family therapy, summary of therapeutic interventions.

The client can be helped by using a number of therapeutic interventions, some of which are as follows:

Supportive psychotherapy is the attempt by a therapist by any practical means whatever to help patients deal with their emotional distress and problems in living. It includes comforting, advising, encouraging, reassuring, and mostly listening, attentively and sympathetically. The therapist provides an emotional outlet, the chance for patients to express themselves and be themselves. Also the therapist may inform patients about their illness and about how to manage it and how to adjust to it. Over the course of treatment he may have to intercede on a patient’s behalf with various authorities, including schools and social agencies, and with the patient’s family- indeed, with all of those with whom the patient may be contending (Neuman, 2013) .

Psycho education refers to the education offered to people who live with a psychological disturbance. Frequently Psycho educational training involves clients with complaints of depression, anxiety, hopelessness, loneliness, eating problems, and sleep problems etc. The main purpose of psycho education is to educate the client about his condition and also its management to help the client to deal with the problem by himself. The client needs to be educated about his problems and what factors are affecting on it and how he can control it. The client should be educated about the importance of self-management and how he can cooperate with his psychologist to make him better. The client’s family also needs to be educated to support him when he needed. Amputation is a triple threat. It involves loss of function, loss of sensation and loss of self-image so it is very important to deal with it. First of all the client will gain insight about the aspects of his problem then he will be able to easily deal with it. The theory is, with better knowledge the client has of her illness, the better the client can live with her condition. Psycho education can be provided to the client and family members together or separately (Hudak& Dougherty, 2011).

Behavioral Therapy

Contingency contract.

Contingency Contracting is a type of intervention that is used to increase desirable behaviors or decrease undesirable ones. A contingency contract may be entered into by a teacher and student, a parent and child, or a therapist and client. It specifies the target behavior, the conditions under which the behavior will occur, and the benefits or consequences that come with meeting or failing to meet the target. This technique will be used to change the behavior of client during studies to motivate him to work hard. This technique will also be used to decrease the anger level in client.

Sleep Hygiene Principle

Go to sleep at about the same time each night, and awaken at the same time each morning.  Wide fluctuations between workdays and days off can further impair your sleep. Try not to nap. If you do, restrict this to about an hour per day, and do it relatively early (before about 4 in the afternoon). If you are not sleepy, either don’t go to bed or arise from bed.  Do quiet, relaxing activities until you feel sleep, then return to bed. Avoid doing stimulating, frustrating, or anxiety provoking activities in the bed or in the bedroom (watching television, studying, balancing the checkbook, etc.).  Try to reserve the bedroom and especially the bed, for sleep.

Exercise, particularly aerobic exercise, is good for both sleep and overall health and should be encouraged. Avoid stimulating exercise in the evening (do this at least 5 hours before bedtime).

Bedtime Ritual

Perform relaxing activities in the hour before bedtime . Make sure your sleeping environment is as comfortable as possible, paying attention to temperature, noise, and light . Do not eat a heavy meal just before bedtime, although a light snack might help induce drowsiness . It is sometimes helpful to place paper and pen by the bedside.  If you find yourself worrying about completing or remembering a task the next day, write it down and let it go.

During the night

If you awaken and find you can’t get back to sleep, arise from bed and do quiet, relaxing activities until you are drowsy.  Then return to bed. Place clocks so that the time is not visible from the bed (Bazil, 2015).

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is the most widely-used therapy for anxiety disorders. Cognitive behavioral therapy addresses negative patterns and distortions in the way we look at the world and ourselves. CBT is one of the most effective treatments for depression, and has been found to be useful for a wide range of people, including children, adolescents, adults and older people.

Behavior Activation

As a treatment for depression and other mood disorders, behavioral activation is based on the theory that, as individuals become depressed, they tend to engage in increasing avoidance and isolation, which serves to maintain or worsen their symptoms. The theory holds that not enough environmental reinforcement or too much environmental punishment can contribute to depression. So, the treatment tends to increase environmental reinforcement and reduce punishment. The goal of treatment, therefore, is to work with depressed individuals to gradually decrease their avoidance and isolation and increase their engagement in activities that have been shown to improve mood. Many times, this includes activities that they enjoyed before becoming depressed, activities related to their values or even everyday items that get pushed aside such as:

Exercising, going out to dinner, improving relationships with their family members, working toward specific work-related goals, learning new skills and activities, Showering regularly and completing household chores etc. this technique will be used for client to decrease his depression level by involving him in different activities (Leahey, 2003).

Activity Schedule

Activity schedule is a written plan of a client’s daily activities. The client and therapist schedule activities for most hours of each day and often incorporates those activities too which the client finds pleasurable. The activity schedule provides clients a sense of direction and control (Leahey, 2003).

Cognitive Rehabilitation

The objective of this technique is to improve cognitive functions of patient, reduce the symptoms and enhance the patient’s adaptive functioning in the real world. It focuses on memory, attention and executive functions (Seligman, Walker & Rosenhan, 2001, p. 462).  It will enhance the memory, attention, concentration, problem solving skills and executive functions of the client.

Rational Emotive Behavior Therapy (REBT) is both a psycho therapeutic system of theory and practices and a school of thought established by Albert Ellis.

This is an active approach for helping clients evaluate the helpfulness and efficacy of elements of their belief systems. Once the client is familiar with the ABCs of REBT, disputing will allow her to identify debate and ultimately replace her thinking and beliefs which are generally getting her into trouble and are the cause of her compulsive acts or maladaptive behavior patterns (Ellis & Maclaren, 1998).

Philosophical Disputes

The philosophical approach addresses a life satisfaction issue. Often the client will have been too focused on the identified problem that he has lost perspective on the other areas of his life. The problem has subsequently become the defining element of the client’s existence. It can be helpful to do some reality testing about other aspects of their life (Ellis & Maclaren, 1998).

Rational Coping Statements

Rational coping statements are self statements which usually are implemented after disputing has been accomplished, but they can also be used when the client is in the process of exploring her beliefs. These factual, encouraging phrases are consistent with social reality and client can be encouraged to repeat them consistently to reinforce the ideas for her. The may be encouraging statements such as “I can accomplish this task” or “I don’t have to get upset in these situations” (Dryden, 1994; Ellis, 1957, 1988; Yankura & Dryden, 1990 as cited in Ellis & Maclaren, 1998).

Biblotherapy / Psycho educational Assignment

In this technique therapist supplement the therapy content with bibliographic / psycho educational assignment to further reinforce the work the client doing in session. Assigning helpful audio cassette, videos, pamphlets, books, lectures, workshops and topic specific group can all contribute to client understanding of his problem and progress in changing inappropriate and unhelpful reactions. As in the client case material was provided to motivate him that many people also have amputee of different limbs but they cope with the situation and are working in a good way (Ellis &Maclaren, 1998).

Mindfulness based cognitive therapy (MBCT)

MBCT is generally delivered in groups and involves learning a type of meditation called ‘mindfulness meditation’. This meditation teaches people to focus on the very present moment, just noticing whatever they are experiencing, be it pleasant or unpleasant, without trying to change it. At first, this approach is used to focus on physical sensations (like breathing), but later it is used to focus on feelings and thoughts. MBCT helps client to stop their mind wandering off into thoughts about the future or the past, or trying to avoid unpleasant thoughts and feelings.

Self Esteem Building

Building your self-esteem and creating a positive self-awareness comes from taking an inventory of your own strengths and abilities as a human being. This “inner peace” does not mean that you are unaware of your weaknesses; it merely means that you accept who you are and genuinely like the person you have become. Low self-esteem is often linked to depression or anxiety. If your emotions feel overpowering or out of control, one way to build self-esteem around this issue is to learn to manage your mood and gain control over your feelings. Some people are able to do this with the help of friends and family. Others need to work with a mental health professional to manage the problems that may lie beneath the surface of low self-esteem (Ponton, 2013).

Anger Management

Relaxation exercise.

Psychologists train patients in a technique called “progressive relaxation” until they’re able to relax simply by thinking of a particular word or image. Psychologists then ask patients to spend a minute or two thinking intensely about a situation that makes them excessively angry, such as other drivers going too slow. Psychologists then help patients relax. Psychologists and patients practice this sequence over and over again. After about eight sessions, patients are typically able to relax on their own (Stearns & Stearns, 1989).

Listing of advantages and disadvantages of anger, distraction from negative thoughts, identifying bodily symptoms associated with anger, using positive statements and identifying positive solutions etc will also be used to treat anger.

Traffic Signal Technique

When teaching anger management to client, a traffic light is effective at encouraging the identification of angry emotions. The color red represents stopping, and is useful when client begin to lose control of their emotions. Yellow offers client an opportunity to think and find an appropriate solution to their problem, and green lets them know they can move forward in a responsible way. Just as a driver who runs a traffic light risks getting a ticket or causing an accident, a client risks punishment, personal injury, or inflicting injury on someone else by running an anger traffic light. The three colors on a traffic light can represent the three stages of emotion a client passes through when becoming angry. Green represents calm and relaxation, or the state before anger begins to develop. Yellow symbolizes the build-up of angry emotion that typically occurs when the client first encounters a stressor. Red represents the client’s reaction to the angry emotions.

Once the client learn to recognize what stage of anger they are in, they can utilize coping strategies learned in anger management programs to stop the progression of their emotions before they reach red. Anger is a complicated and overwhelming emotion, but using a traffic light for anger management allows client to visualize their anger and the steps necessary for controlling their reaction to angry emotions (Ketcham, 2015).

All human beings require a support system throughout life in order to maintain emotional health. However, not all are so blessed, and many find themselves transiently or permanently in state of isolation. Single and widowed individuals suffer more psychological distress and difficulty in adapting to amputation than do those who are married and have a family. Particularly helpful in adjustment of the adult amputee is the presence of a supportive partner who assumes a flexible approach, takes over functions when needed, cuts back when the amputee is able to manage, but at all times maintains the amputee’s self-esteem. Parents are the major source for children and adolescent amputees but peer acceptance beyond the family is critical in the successful adaptation of all amputees and especially children and adolescents (Racy, 2015).

Limitations

• The environment of hospital was not appropriate for psychological assessment. There was not any appropriate place for conducting assessment and the place where the assessment was carried out had many distractions which sometimes made it difficult for the client to concentrate.
• The time given to carry out the assessment was too short and it was impossible to collect the complete, detailed and in depth information about the client in that short period of time.
• No follow up session was done to see the effect of techniques that client learned in session.

Suggestions

• The client and his family should accept that client’s was amputee and it takes time for him to cope with this problem a disease in which progress is very slow so they have to work together for the treatment to work.
• Client’s family should support him so that he will be able to fight with that problem.
• The client and family should be prepared that it is a long term treatment for that problem so time needs for him to reach his normal emotional state and do his tasks by himself.
• There should be a proper room for carrying out the psychological assessment and intervention of the client. A place where there is no such thing which can distract the client during assessment.
• Sufficient time should be given for the rapport building and for getting the complete and comprehensive information about the client and also for the follow up sessions.

Also Study: Psychological Assessment Example

References;

• Cansever A, Uzun O, Yildiz C, et al. Depression in men with traumatic lower part amputation: A comparison to men with surgical lower part amputation. Mil Med. 2003;168:106–9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
• Ellis, A. &Maclaren, C. (1998). Rational emotive behavior therapy: A therapist guide . USA: Impact Publishers, Inc.
• Frank RG, Kashani JH, Kashani SR, et al. Psychological response to amputation as a function of age and time since amputation. Br J Psychiatry. 1984;144:493–7.Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
• Frierson RL, Lippmann SB. Psychiatric consultation for acute amputees. Psychosomatics.1987;28:183–9 Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
• Hudak, R. & Dougherty, D. (2011). Clinical obsessive-compulsive disorders in adults and children. UK: Cambridge University press
• Ketcham, S. (2015). Using a Traffic Light for Anger Management. Retrieved from https://stress.lovetoknow.com/Using_a_Traffic_Light_for_Anger_Management
• Kindon D, Pearce T. In: Psychosocial Assessment and Management of the Amputee in Rehabilitative Management of the Amputee. Banerjee S, editor. London: Williams and Wilkins; 1982. pp. 350–71.
• Kohl S. The process of psychological adaptation to traumatic limb loss. In: Krueger DW, editor.Emotional Rehabilitation of Physical Trauma and Disability. New York: SP Medical and Scientific Books; 1984. pp. 113–48.
• Kohl SJ. In: Emotional Coping with Amputation in Rehabilitation Psychology: A Comprehensive Textbook. Krueger DW, editor. Rockville, MD: Aspen; 1984. pp. 273–82.
• Leahy, R. L (2003). Cognitive Therapy Techniques . New York: Guilford Press.
• McNaughty,  J. K. (2015). Amputation: Evaluating Psychological Injuries in Children and Adults. Retrieved from https://www.experts.com/Articles/Amputation-Evaluating-Psychological-Injuries-Children-Adults-By-Dr-Jane-McNaught
• Neuman, F. (2013). Supportive Psychotherapy. Retrieved from https://www.psychologytoday.com/blog/fighting-fear/201306/supportive-psychotherapy
• Ponton, L. (2013). Building Self Esteem. Retrieved from https://psychcentral.com/lib/building-self-esteem/
• Racy, J. C. (2015). Psychological Adaptation to Amputation. Retrieved from https://www.oandplibrary.org/alp/chap28-01.asp
• Ratto, L. L. (2014). Coping with a Siblings Disability. Retrieved from https://www.amputee-coalition.org/inmotion/jun_jul_96/copsibs.html
• Seligman, M. E. P., Walker, E. F., & Rosenhan, D. L. (2001). Abnormal psychology (4 th ed.). USA: W W Norton & Company.
• Shula GD, Sahu SC, Tripathi RP, et al. A psychiatric study of amputees. Br J Psychiatry.1982; 141:50–3. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
• Spiegler, M. D &Gueveremont D. C (1998). Contemporary behavior therapy . USA: Cole publishing company.

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plz give me some cases reports.

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I need some sample cases, with the diagnosis of the problem, assessment of the client, formulation of counselling goals, interventions, and assignment gaven.

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l also need some sample cases with the diagnosis of the problems, assessment of the client and interventions.

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I need some reports of counselling

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