case study in counselling examples

How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

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Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

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Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Person-Centered Therapy Case Study: Examples and Analysis

By: Tasha Kolesnikova

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a form of psychotherapy developed by prominent American psychologist Carl Rogers throughout the 1940s to the 1980s. This type of therapy is a humanistic approach and was seen as revolutionary as most psychotherapies before its emergence was based on behaviorist and psychodynamic approaches. The humanistic approach directly contradicts and contrasts core techniques and models of other approaches that were commonly used at the time.

What Is Person-Centered Therapy?

5 characteristics of the fully functioning person, causes of incongruence, person-centered therapy in practice, person-centered case study, person-centered treatment plan.

Nowadays, the fundamental modalities of person-centered therapy are widely used in modern counseling practices in combination with other techniques and therapies. Rogers is often considered the father of all humanistic schools of therapy, as many new therapies have since stemmed from his work. 

Students can use this article as a resource to help them with an academic essay  about person-centered therapy. 

Person-centered therapy focuses on facilitating  self-actualization .  The therapy is built upon the fundamental ideology that human beings have an innate desire and ability to be the best they can be and live happy, fulfilling lives. An individual must set their own goals, and proceed to approach them in their own way. Once these goals have been met, self-actualization is also achieved and, as a result, they will become a  fully functioning person . 

It also promotes the notion that all individuals have the ability to cope with their problems and possess the potential for change. These abilities are unique to each individual, and therefore, everyone has the power to formulate appropriate solutions to help themselves navigate and manage their lives.

Positive growth can be achieved when an individual has positive regard for themselves and from others. Once optimal levels are reached, the individual will become fully functioning. Under this self-concept, it is believed that every individual has:

• the capacity for self-awareness
• the need for meaning in their life
• the need for balancing freedom and responsibility

The key part of the person-centered approach is to assist individuals in self-discovery and self-acceptance by providing sufficient conditions that help resolve incongruence between themselves and their experiences.

According to Rogers, a fully functioning person has the following five characteristics:

• They are  open to new experiences , both positive and negative. They accept that life can sometimes be painful, but they have healthy abilities to cope and learn from them.
• They are  mindful and focus on present  experiences without preconceptions from previous experiences. They do not dwell on the past or obsess about the future.
• They are  aware of and attentive to facts ,  feelings, and gut reactions . Unity of all three allows them to be true to themselves and thus have the confidence to make the right decisions. If the wrong choice is made, they will be able to accept it and learn from it.
• They are  willing to take risks and be adaptive . They will seize healthy and appropriate opportunities for growth.
• They  have a sense of contentment  and a desire for new challenges and experiences.

Each of these characteristics is achieved through congruence of the self.

An individual tends to struggle with becoming a fully functional person, mostly due to incongruence. Incongruence is usually caused by encountering conditional worth or conditional love at some point, often during childhood.

If love and worth are dependent on meeting specific expectations and withdrawn when these expectations were not met, the individual will suffer from anxiety. This anxiety leads to a feeling of the unified self-being under attack. To relieve this anxiety, the individual will engage in detrimental methods such as denial and defensiveness.

Another cause is frustrated basic impulses that lead to negative feelings and poor social skills.

Individuals receiving person-centered therapy are referred to as clients rather than patients. This is in line with the overall concept that therapy is a shared journey between two people rather than the therapist or counselor treating or giving the advice to solve problems. The client is regarded as the expert of themselves and has all the answers to their own problems required within them.

Sufficient core conditions required for therapeutic change under person-centered therapy are outlined as follows:

• Psychological contact  - a mutually respectful relationship between the counselor and patient must exist, where both parties feel equally important.
• Client incongruence  – the client must experience distress caused by incongruence between their experiences and awareness. They are vulnerable and or anxious.
• Therapist congruence or genuineness  – sometimes referred to as being authentic. The therapist must be aware of their active participation and be deeply involved, becoming congruent with the therapeutic relationship.
• Therapist unconditional positive regard  – the therapist or counselor must have a non-judgmental stance, so the counselor does not impose any conditions of worth.
• Therapist empathy  – the therapist or counselor must effectively and accurately communicate their empathic understanding of the client's frame of reference. Presenting problems from another perspective can also help the client gain a new point of view to solving them.
• Client perception  – the client must perceive and appreciate this empathy and acceptance from their therapist or counselor and develop positive self-regard to a minimal degree.

It is interesting to note that Rogers viewed both approval and disapproval shown towards an individual to be disruptive to therapeutic change. The role of the therapist is to provide a caring and accepting environment conducive to giving clients the freedom to explore areas of their lives in ways they were previously denied or distorted. 

Unlike other therapies, Person-centered therapy does not have many set techniques. This Is because therapy sessions are largely directed by the individual. The counselor's or therapist's job is to create a safe environment that facilitates congruence and form a therapeutic alliance with the individual.

Because of this, a defining technique used during person-centered therapy is  non-directiveness . This is achieved by:

• giving no advice
• asking no questions
• giving no interpretations
• allowing clients to set their own goals

Another technique used during therapy sessions is  active listening . This is achieved by:

• paraphrasing
• summarizing

It was theorized that the client will initially be closed, not open to experiences, and have little to no self-awareness. But once therapy is completed, all these obstacles will be addressed and reversed due to gaining positive self-regard.

There are many advantages in the techniques used during person-centered therapy. However, some concerns have also been raised about the approach:

• Non-directiveness  - idea of non-directiveness has been largely debated. Some have argued that therapy by nature will always be directed in some capacity. Furthermore, bias can never be completely eliminated. Therefore, unconscious or unintentional bias can cause direction.
• Inefficient  – person-centered therapy can take an unnecessarily long time due to the lack of structure and non-directiveness. For fear of intervening with progress, therapists may deliberately withhold solutions or advice from a client, and it may take longer than necessary to reach that solution, if at all.
• Frustration  – being non-direct can understandably cause frustration in some clients who may be seeking advice or opinions.
• Disorder specific  – Rogers originally claimed that Person-centered therapy could treat all mental health disorders, but research has shown this is not the case.

Jane's phenomenological worldview causes her to be incongruent with her true self and what she believed is expected of her. Expectations imposed upon her are unrealistically high, and fear of not meeting those standards has caused her incongruent distress. Subsequently, this has created a condition for her self-worth.

These expectations are a direct result of traumatic stress stemming from culture, religion, and loved ones. In her phenomenological world, she will never be good enough as a daughter, mother, wife, Catholic, or accountant. She feels she constantly lets everyone down and can never gain approval from those whose opinions she cares about.

Trying harder to please and meet everyone's expectations takes her further away from wholeness and true self-worth. She has lost confidence in her ability to make good decisions and constantly seeks outside direction on how she should act. This low self-esteem will hinder any feelings of success and satisfaction.

She is aware that how she handles situations as it stands is not working but fails to see the situation from another perspective or figure out new solutions.

This is a classic example of a client that may benefit from person-centered therapy. We can understand that although Jane feels these pressures of meeting rejection and disapproval, she still has the potential for self-actualization.

This is evidenced by her independent decisions of marrying a spouse outside her religion and studying accountancy against her family's wishes. The act of seeking therapy confirms her desire for growth and change for a better life.

Jane has risen above adversity on multiple occasions in life. She has achieved academically, personally, and professionally but the lack of caring relationships has distorted her ability to recognize and accept her success and potential. This has deterred her from achieving higher levels of self-actualization. Jane must take new risks to attain the growth she seeks. 

For treatment to be effective, the core conditions must be met. The formulation was as follows:

• Undertaking person-centered therapy, the therapist will provide an optimal therapeutic environment where her actualizing tendencies can flourish.
• Through active listening and empathy, the therapist and Jane will build a trusting therapeutic alliance and further clarify her thoughts and feelings. Being able to work out problems and breaking them down, Jane will no longer view them as insurmountable as she did before.
• Unconditional positive regard will install confidence in Jane as a competent person capable of making decisions and problem solving on her own. By increasing trust in herself, she reduces the control others have over her and will begin to believe in her own self-worth.
• Consistency and genuine rapport between Jane and the counselor will allow her to feel that the ideas and actions developed during sessions are authentic, dependable, and can be replicated outside in the real world.
• Jane's newfound view of the world will lead to her trying out new approaches to problems. She will continue to report back on her progress in integrating these new approaches. She will eventually come to recognize that she is capable of independently achieving success and overcoming failure.
• Jane will continue these practices until she has reached self-actualization and becomes a fully functional person.

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041 – Writing Case Studies – Carl Rogers’ 19 Propositions – Counselling Skills

In episode 41 of the Counselling Tutor Podcast, Rory Lees-Oakes and Ken Kelly describe how to write a case study. ‘Theory with Rory’ looks at how best to apply the 19 propositions when writing case studies and assignments. Last, the presenters talk about diversity in the counselling room.

Writing Case Studies (starts at 3.26 mins)

Ken and Rory offer a number of tips on writing case studies as a student:

• Always check the criteria set by your awarding body before you start writing.
• Open the case study with a ‘pen portrait’ of the client – e.g. age, gender and presenting issue.
• Continue by describing the client’s counselling journey, from start to finish.
• Depending on the criteria you are working to, there are various themes you can develop – for example, ethics , the theory of your modality, and your self-awareness during the work.
• It is always good to reflect on your own learning from your sessions with the client, and how you might approach things differently in future.

Carl Rogers’ 19 Propositions (starts at 13.51 mins)

The 19 propositions were developed by Carl Rogers, the founder of person-centred therapy. They describe his theory of personality, expressed in terms of how a human being perceives the world (i.e. phenomenology). This part of person-centred theory is often seen as particularly hard to ‘decode’. Rory has done so previously in Counselling Tutor Podcasts 13 and 14 . One key tip he offers when reading Rogers’ original wording is to swap the word ‘organism’ for ‘person’.

Rory offers three insights into how you can make maximum use of the 19 propositions when writing case studies and assignments. For example, you can use this theory to:

• evidence how clients engage with their incongruent selves
• describe how, in making sense of their reality, clients can transcend it (as the philosopher Edmund Husserl believed that once indivuduals understand their reality, they can then transcend it)
• explain how clients engage with their truth and what changes they make as a consequence of that.

Key to all these is to use client statements from counselling interactions to illustrate your points.

For more information, you can download Rory’s handout, ‘Three Positions in Phenomenology : The 19 Propositions’.

Free Handout Download

19 Propositions: Three Positions in Phenomenology

Counselling Skills (starts at 19.40 mins)

In counselling training, it is harder to demonstrate our use of skills than our understanding of theory (which can be written about in assignments). Because our work with clients is subject to confidentiality, we must showcase our grasp of skills through simulated sessions with peers. This can feel rather artificial, with a pressure to somehow slot in every skill in order to meet the criteria.

Ken’s new book, Basic Counselling Skills: A Student Guide is a great resource for skills development at all qualification levels. Uniquely, this includes links to online audio recordings of skills demonstrations. The effect of each skill is explored. As shown in research by Catherine Goldsmith at the University of Manchester, which led to the dodo bird conjecture , the key to effective therapy is primarily the relationship between the patient and therapist. Good counselling skills are key to building this relationship.

Rogers used to audio record client sessions and listen back to these for learning. Recording is really useful for student counsellors; Ken strongly recommends doing so as much as possible (with client consent). Voice recorders can be purchased inexpensively these days.

Links and Resources

Counselling Study Resource

Counselling Tutor Facebook group

Counselling Tutor website

Basic Counselling Skills: A Student Guide

Case Example: Jill, a 32-year-old Afghanistan War Veteran

This case example explains how Jill's therapist used a cognitive intervention with a written worksheet as a starting point for engaging in Socratic dialogue. 

About this Example

Jill's Story

Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck. Over the years, Jill became increasingly depressed and began using alcohol on a daily basis to help assuage her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children. In addition to a range of other PTSD symptoms, Jill had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly to repair it. Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed.”

After a thorough assessment of her PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, Jill received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings. These worksheets were used to sensitize Jill to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on.” She recorded her related feeling to be guilt. Jill’s therapist used this worksheet as a starting point for engaging in Socratic dialogue, as shown in the following example:

Therapist: Jill, do you mind if I ask you a few questions about this thought that you noticed, “I should have had them wait and not had them go on?”

Client: Sure.

Therapist: Can you tell me what the protocol tells you to do in a situation in which a truck breaks down during a convoy?

Client: You want to get the truck repaired as soon as possible, because the point of a convoy is to keep the trucks moving so that you aren’t sitting ducks.

Therapist: The truck that broke down was the lead truck that you were on. What is the protocol in that case?

Client: The protocol says to wave the other trucks through and keep them moving so that you don’t have multiple trucks just sitting there together more vulnerable.

Therapist: Okay. That’s helpful for me to understand. In light of the protocol you just described and the reasons for it, why do you think you should have had the second truck wait and not had them go on?

Client: If I hadn’t have waved them through and told them to carry on, this wouldn’t have happened. It is my fault that they died. (Begins to cry)

Therapist: (Pause) It is certainly sad that they died. (Pause) However, I want us to think through the idea that you should have had them wait and not had them go on, and consequently that it was your fault. (Pause) If you think back about what you knew at the time — not what you know now 5 years after the outcome — did you see anything that looked like a possible explosive device when you were scanning the road as the original lead truck?

Client: No. Prior to the truck breaking down, there was nothing that we noticed. It was an area of Iraq that could be dangerous, but there hadn’t been much insurgent activity in the days and weeks prior to it happening.

Therapist: Okay. So, prior to the explosion, you hadn’t seen anything suspicious.

Client: No.

Therapist: When the second truck took over as the lead truck, what was their responsibility and what was your responsibility at that point?

Client: The next truck that Mike and my other friends were on essentially became the lead truck, and I was responsible for trying to get my truck moving again so that we weren’t in danger.

Therapist: Okay. In that scenario then, would it be Mike and the others’ jobs to be scanning the environment ahead for potential dangers?

Client: Yes, but I should have been able to see and warn them.

Therapist: Before we determine that, how far ahead of you were Mike and the others when the explosion occurred?

Client: Oh (pause), probably 200 yards?

Therapist: 200 yards—that’s two football fields’ worth of distance, right?

Client: Right.

Therapist: You’ll have to educate me. Are there explosive devices that you wouldn’t be able to detect 200 yards ahead?

Client: Absolutely.

Therapist: How about explosive devices that you might not see 10 yards ahead?

Client: Sure. If they are really good, you wouldn’t see them at all.

Therapist: So, in light of the facts that you didn’t see anything at the time when you waved them through at 200 yards behind and that they obviously didn’t see anything 10 yards ahead before they hit the explosion, and that protocol would call for you preventing another danger of being sitting ducks, help me understand why you wouldn’t have waved them through at that time? Again, based on what you knew at the time?

Client: (Quietly) I hadn’t thought about the fact that Mike and the others obviously didn’t see the device at 10 yards, as you say, or they would have probably done something else. (Pause) Also, when you say that we were trying to prevent another danger at the time of being “sitting ducks,” it makes me feel better about waving them through.

Therapist: Can you describe the type of emotion you have when you say, “It makes me feel better?”

Client: I guess I feel less guilty.

Therapist: That makes sense to me. As we go back and more accurately see the reality of what was really going on at the time of this explosion, it is important to notice that it makes you feel better emotionally. (Pause) In fact, I was wondering if you had ever considered that, in this situation, you actually did exactly what you were supposed to do and that something worse could have happened had you chosen to make them wait?

Client: No. I haven’t thought about that.

Therapist: Obviously this was an area that insurgents were active in if they were planting explosives. Is it possible that it could have gone down worse had you chosen not to follow protocol and send them through?

Client: Hmmm. I hadn’t thought about that either.

Therapist: That’s okay. Many people don’t think through what could have happened if they had chosen an alternative course of action at the time or they assume that there would have only been positive outcomes if they had done something different. I call it “happily ever after” thinking — assuming that a different action would have resulted in a positive outcome. (Pause) When you think, “I did a good job following protocol in a stressful situation that may have prevented more harm from happening,” how does that make you feel?

Client: It definitely makes me feel less guilty.

Therapist: I’m wondering if there is any pride that you might feel?

Client: Hmmm...I don’t know if I can go that far.

Therapist: What do you mean?

Client: It seems wrong to feel pride when my friends died.

Therapist: Is it possible to feel both pride and sadness in this situation? (Pause) Do you think Mike would hold it against you for feeling pride, as well as sadness for his and others’ losses?

Client: Mike wouldn’t hold it against me. In fact, he’d probably reassure me that I did a good job.

Therapist: (Pause) That seems really important for you to remember. It may be helpful to remind yourself of what you have discovered today, because you have some habits in thinking about this event in a particular way. We are also going to be doing some practice assignments that will help to walk you through your thoughts about what happened during this event, help you to remember what you knew at the time, and remind you how different thoughts can result in different feelings about what happened.

Client: I actually feel a bit better after this conversation. 

Another thought that Jill described in relation to the traumatic event was, “I should have seen the explosion was going to happen to prevent my friends from dying.” Her related feelings were guilt and self-directed anger. The therapist used this thought to introduce the cognitive intervention of "challenging thoughts" and provided a worksheet for practice. The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors. 

More specifically, Jill noted that she experienced 100 percent intensity of guilt and 75 percent intensity of anger at herself in relation to the thought "I should have seen the explosive device to prevent my friends from dying." She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information (because others don't blame her), and that her feelings are not based on facts (i.e., she feels guilt and therefore must be guilty). She came up with the alternative thought, "The best explosive devices aren't seen and Mike (driver of the second truck) was a good soldier. If he saw something he would stopped or tried to evade it," which she rated as 90 percent confidence in believing. She consequently believed her original thought 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self.

Treating PTSD with cognitive-behavioral therapies: Interventions that work

This case example is reprinted with permission from: Monson, C. M. & Shnaider, P. (2014). Treating PTSD with cognitive-behavioral therapies: Interventions that work . Washington, DC: American Psychological Association. 

Other Case Examples

• Cognitive Therapy Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)
• Eye Movement Desensitization and Reprocessing Mike, a 32-year-old Iraq War Veteran
• Narrative Exposure Therapy Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)
• Prolonged Exposure Terry, a 42-year-old earthquake survivor

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Case conceptualization: Key to highly effective counseling

By Jon Sperry and Len Sperry

December 2020

I n their first session, the counseling intern learned that Jane’s son had been diagnosed with brain cancer. The therapist then elicited the client’s thoughts and feelings about her son’s diagnosis. Jane expressed feelings of guilt and the thought that if she had done more about the early symptoms, this never would have happened to her son. Hearing this guilt producing thought, the intern spent much of the remaining session disputing it. As the session ended, the client was more despondent.  

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.

Presentation

Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.

Predisposition

Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.

Precipitants

Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.

Perpetuants

Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.  

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids cl oseness to avoid perceived harm

Predisposition:

• Biological: Paternal history of anxiety
• Psychological: Views herself as inadequate and others as critical; deficits in assertiveness skills, self-soothing skills and relational skills
• Social: Few friends, a history of social anxiety, and parents who were highly successful and critical
• Cultural: No acculturative stress or cultural stressors but from upper-middle-class socioeconomic status, so from privileged background — access to services and resources

Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation) . A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant) . She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern) . Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants) .

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors) .

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological) ; she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological) ; she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social) . Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural) .

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment) .

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis) .

Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence .

Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at [email protected] or visit his website at drjonsperry.com .

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Doing Research in Counselling and Psychotherapy

Student resources, carrying out a systematic case study.

The key messages of this chapter are:

• case study analysis makes a distinctive contribution to the evidence base for counselling and psychotherapy
• case studies are ethically sensitive, so need to be carried out with care and sensitivity
• it is important to be aware of how different types of research question require different case study approaches.

The following sources are intended to help you to explore issues covered in the chapter in more depth.

Methodological issues and challenges associated with case study research

Flyvbjerg, B. (2006). Five misunderstandings about case-study research . Qualitative Inquiry, 12 , 219 – 245. 

Essential reading – a highly influential paper that clarifies the value of case study methods

Fishman, D. B. (2005). Editor's Introduction to PCSP--From single case to database: a new method for enhancing psychotherapy practice.  Pragmatic Case Studies in Psychotherapy, 1(1), 1 – 50.

The rationale for the pragmatic case study approach

Foster, L.H. (2010). A best kept secret: single-subject research design in counseling.  Counseling Outcome Research and Evaluation,  1, 30 – 39

An accessible and informative introduction to n=1 single subject case study methodology  

McLeod, J. (2013). Increasing the rigor of case study evidence in therapy research.  Pragmatic Case Studies in Psychotherapy, 9 , 382 – 402

Explores further possibilities around the development of case study methodology

Different types of therapy case study

Bloch-Elkouby, S., Eubanks, C. F., Knopf, L., Gorman, B. S., & Muran, J. C. (2019). The difficult task of assessing and interpreting treatment deterioration: an evidence-based case study.  Frontiers in Psychology , 10, 1180. 

Systematic case study that combines qualitative and quantitative information to explore a theoretically-significant case of apparent client deterioration. Case was drawn from dataset of a larger study

Brezinka, V., Mailänder, V., & Walitza, S. (2020). Obsessive compulsive disorder in very young children–a case series from a specialized outpatient clinic.  BMC Psychiatry , 20(1), 1 – 8. 

Example of how a series of n=1 case studies can be used

Faber, J., & Lee, E. (2020). Cognitive-Behavioral Therapy for a refugee mother with depression and anxiety.  Clinical Case Studies , 19(4), 239 – 257.

A hybrid theory-building/pragmatic case study that seeks to develop new understanding of therapy in situations of client-therapist cultural difference. Clinical Case Studies is a major source of case study evidence – this study is a typical example of the kind of work that it publishes  

Gray, M.A. & Stiles, W.B. (2011). Employing a case study in building an Assimilation Theory account of Generalized Anxiety Disorder and its treatment with Cognitive-Behavioral Therapy. Pragmatic Case Studies in Psychotherapy , 7(4), 529 – 557

An example of a theory-building case study focused on the development of the assimilation model of change 

Kramer, U. (2009).  Between manualized treatments and principle-guided psychotherapy: illustration in the case of Caroline.  Pragmatic Case Studies in Psychotherapy , 5(2), 45 – 51

A pragmatic case study that also seeks to address important theoretical issues associated with the use of exposure techniques in CBT

McLeod, J. (2013). Transactional Analysis psychotherapy with a woman suffering from Multiple Sclerosis: a systematic case study.  Transactional Analysis Journal,  43 , 212 – 223.

A hybrid case study – mainly aims to develop a theory of therapy in long-term health conditions, but also includes elements of pragmatic, narrative and HSCED approaches. Good example of the use of the Client Change Interview in case study research

Powell, M.L. and Newgent, R.A. (2010) Improving the empirical credibility of cinematherapy: a single-subject interrupted time-series design.  Counseling Outcome Research  
 and Evaluation , 1, 40 – 49. 

Example of a series of n=1 case studies

Stige, S. H., & Halvorsen, M. S. (2018). From cumulative strain to available resources: a narrative case study of the potential effects of new trauma exposure on recovery.  Illness, Crisis & Loss , 26(4), 270 – 292. 

A narrative case study based on client interviews

Kellett, S., & Stockton, D. (2021). Treatment of obsessive morbid jealousy with cognitive analytic therapy: a mixed-methods quasi-experimental case study.  British Journal of Guidance & Counselling , 1 – 19. 

Example of an n=1 case study of a single case. Useful demonstration of how this approach can be used to study non-behavioural therapy

Wendt, D. C., & Gone, J. P. (2016). Integrating professional and indigenous therapies: An urban American Indian narrative clinical case study.  The Counseling Psychologist , 44(5), 695 – 729. 

A narrative case study based on client interviews 

Werbart, A., Annevall, A., & Hillblom, J. (2019). Successful and less successful psychotherapies compared: three therapists and their six contrasting cases. Frontiers in Psychology . DOI: 10.3389/fpsyg.2019.00816.                  

Combined narrative, theory-building and cross-case analysis, based on interviews with client and therapist dyads

Widdowson, M. (2012). TA treatment of depression: A hermeneutic single-case efficacy design study-case three: 'Tom'.  International Journal of Transactional Analysis Research , 3(2), 15 – 27. 

Example of an HSCED study that also includes elements of theory-building. Supplementary information on journal website includes full details of the Change Interview and judges’ case analyses. This open access journal has also published many other richly-described HSCED studies

Issues and possibilities associated with quasi-judicial methodology

Bohart, A.C., Tallman, K.L., Byock, G.and Mackrill, T. (2011). The “Research Jury” Method: The application of the jury trial model to evaluating the validity of descriptive and causal statements about psychotherapy process and outcome.  Pragmatic Case Studies in Psychotherapy, 7 (1) ,101 – 144. 

Miller, R.B. (2011). Real Clinical Trials (RCT) – Panels of Psychological Inquiry for Transforming anecdotal data into clinical facts and validated judgments: introduction to a pilot test with the Case of “Anna”.  Pragmatic Case Studies in Psychotherapy, 7(1), 6 – 36. 

Stephen, S. and Elliott, R. (2011). Developing the Adjudicated Case Study Method.  Pragmatic Case Studies in Psychotherapy, 7(1), 230 – 224.

Case Examples

I would not exchange or trade the honor and privilege I have had helping individuals, couples and families since 1987. Along this journey, I experienced many situations of success and seeing people grow and share their positive outcomes.

Below you will find a sample of cases where a client has given me permission to share their experience. Identifying information has been changed to protect confidentiality.

Dr. Chen is a good therapist.  He has helped me clarify perceptions that have blocked my growth and development.  I have been able to resolve the feelings that have grown from the misperceptions.  In counseling, I have learned new attitudes and language to help improve my marriage and family relationships.  The barriers I have built up over the years are being removed.  This process takes a long time, but I think it has moved at an appropriate pace.  Other counselors have taken much longer to help me even begin the healing process.  I have made great progress while working with Dr. Chen.

Dear Dr. Chen,

I am writing to express my appreciation for your knowledge and understanding in helping us deal with our teenager’s issues. We were very distraught when we learned about our child’s problems. As with any parent, we were concerned for our child and feared for the worst. We didn’t know what to expect or how to help our child.

Your extensive knowledge and expertise helped us understand what was going on and provided comfort and reassurance. Your expertise and ability to relate to our situation helped us get through a very difficult time.

Thank you for the competence and calm demeanor you displayed as you helped reassure us during this critical time. I firmly believe that others facing similar problems would greatly benefit from your services.

Thanks again, Bruce L.

After suffering with trichotillomania for 15 years, I felt trapped by my constant urges to pull my hair.  3 weeks after seeking professional help from you, I was able to greatly reduce the amount I pulled my hair.  By using the tools I learned in therapy, I can go several days at a time without pulling and am continually improving.

Thank you! Kelsey

Alcoholic Alan

Not long ago a client (Alan) came in seeking help for drug and alcohol abuse. He was in his mid 30’s and had been using marijuana, cocaine and methamphetamine since his late teenage years. He started drinking alcohol before he was a teenager.

Alan finished high school and began working in retail. He changed jobs or was fired every couple years but was able to work his way up into a manager position. He was married and had three children. His drinking had a negative impact on his family and occasionally he yelled at his wife and kids. Often he spent time by himself at home watching T.V. or surfing on the Internet.

He wasn’t very satisfied at work and occasionally got into arguments with his assistant manager.  During therapy, it became evident that Alan used drugs and alcohol to cover up his feelings of anger, frustration and at times low self-esteem.

He was able to learn new coping skills and reduce his use of drugs and alcohol. His marriage improved and he enjoyed his kids more. Even his relationship with his assistant manager improved.

Co-dependent Cathy

Cathy had been married for 14 years to her high school sweetheart. Things started out good but as their family grew to four children the first five years, their marital relationship gradually deteriorated. Her husband, a sales manager traveled almost every week. When he was home, he tended to ignore her and the kids.

Cathy would occupy herself with housework, church duties and helping neighbors and other relatives. Most people thought Cathy had a good marriage, but inside she felt empty and trapped.

Feelings of frustration and anger would occasionally rise to the surface, but most of the time she just kept it all inside.

When Cathy started therapy, she had just discovered her husband had an addiction to pornography. She was surprised, hurt, angry and didn’t know whether she wanted to stay in the marriage or leave. She was concerned about the kids.

The therapy focused on a pattern of behavior called co-dependency. Cathy discovered that her husband was in many ways like her father, who was an alcoholic. She tried to control her family growing up and now she was trying to control her husband.

Gradually Cathy developed a healthy mental separation from her husband and as she began to get healthy, her husband admitted he had a problem with pornography and decided to get help himself.

Anxious Ann

Ann was in her late 20’s and had been working in a secretarial position since graduating from high school. She was nervous and anxious most of the time. She rarely dated but desperately wanted to get married.

However, Ann was afraid to socialize and had few friends. Most evenings she would read a book at home or talk on the phone to her parents or other relatives.

By the time Ann came to therapy, she had begun to have panic attacks and at times she thought she might die. Therapy began by exploring why Ann was not dating. It was discovered that she had been sexually abused by a baby sitter when she was 7 years old. This abuse continued over a two year period. She had never told her parents. Later she was also sexually abused by an uncle.

Ann had strong feelings of anger toward men but also wanted to develop a relationship with a man and eventually get married. Her feelings of ambivalence had developed into anxiety which lead her to isolate and avoid men.

During therapy Ann was able to work through the trauma of the two different periods of sexual abuse. Her anxiety disappeared and then therapy focused on helping her develop appropriate social skills. Ann began dating and recently became engaged.

Depressed Donna

Donna was in her mid 40’s, a typical mother of 4 children, married for over 16 years and active in the community and church.}

She had her first depression with the birth of her first child, and her family doctor prescribed an anti-depressant.

Her husband was supportive and made a decent income, yet money always seemed tight. It was a challenge taking each of the four children to music lessons, dance, football practice and the like, not to mention all the church activities.

Donna never felt like there was any time for herself. In fact, if she did take time to do something she enjoyed, she felt guilty.

She tried to talk to her church leader once, but that didn’t seem to help. She knew there were other women who were depressed and taking medication, but she still felt like no one understood what she was going through.

When she finally came to therapy, she felt hopeless but wanted to change her life. In therapy, she learned to develop some positive thinking skills, not just think happy thoughts, but really challenge some of her long held beliefs that kept her from finding the peace and happiness she knew she had always sought.

She began to enjoy life more and her husband even commented how much happier she seemed. The best compliment was from one of her children who said “mommy, you don’t seem like you’re mad at me anymore”. Donna almost cried. The mixture of joy and sadness she had; joy that she could connect better to her husband and children, and sadness that she hadn’t sought help sooner.

Career Confusion

Tom was in his late 40’s and ready for a new challenge in his life. He had worked in the computer industry for over 20 years and was recently let go from one of the major computer companies.

He first got into the computer industry because it was exciting and new developments were happening all the time. But over the years he became upset by the lack of loyalty that large companies showed their employees.

This was the third time he was a “victim” of a downsizing and he was ready to bail out of computers. But he didn’t have a clue what to do.

When Tom came to career counseling, the first question he asked was “What else am I good at?” He took a battery of assessments and found that he had natural abilities in the science and technology areas. The more he explored, the more interested he became in fixing scientific devices. He enrolled in a course designed to help technicians fix medical devices.

During this course he met another entrepreneur and together they developed a business plan. Tom had found a new challenge and was ready to move forward.

John Sommers-Flanagan

A short existential case example from counseling and psychotherapy theories . . ..

Each chapter in Counseling and Psychotherapy Theories in Context and Practice includes at least two case vignettes. These vignettes are brief, but designed to articulate how clinicians can use specific theories to formulate cases and engage in therapeutic interactions. The following case is excerpted from the Existential Theory and Therapy chapter.

This post is part of a series of free posts available to professors and students in counseling and psychology who are teaching and learning about theories of counseling and psychotherapy. It, as well as the recommended video clip at the end, can be used for discussion purposes and/or to supplement course content.

Vignette II: Using Confrontation and Visualization to Increase Personal Responsibility and Explore Deeper Feelings

In this case, a Native American counselor-in-training is working with an 18-year-old Latina female. The client has agreed to attend counseling to work on her anger and disruptive behaviors within a residential vocational training setting. Her behaviors are progressively costing her freedom at the residential setting and contributing to the possibility of her being sent home. The client says she would like to stay in the program and complete her training, but her behaviors seem to say otherwise.

Client: Yeah, I got in trouble again yesterday. I was just walking on the grass and some “ho” told me to get on the sidewalk so I flipped her off and staff saw. So I got a ticket. That’s so bogus.

Counselor: You sound like you’re not happy about getting in trouble, but you also think the ticket was stupid.

Client: It was stupid. I was just being who I am. All the women in my family are like this. We just don’t take shit.

Counselor: We’ve talked about this before. You just don’t take shit.

Client: Right.

Counselor: Can I be straight with you right now? Can I give you a little shit?

Client: Yeah, I guess. In here it’s different.

Counselor: On the one hand you tell me and everybody that you want to stay here and graduate. On the other hand, you’re not even willing to follow the rules and walk on the sidewalk instead of the grass. What do you make of that?

Client: Like I’ve been saying, I do my own thing and don’t follow anyone’s orders.

Counselor: But you want to finish your vocational training. What is it for you to walk on the sidewalk? That’s not taking any shit. All you’re doing is giving yourself trouble.

Client: I know I get myself trouble. That’s why I need help. I do want to stay here.

Counselor: What would it be like for you then . . . to just walk on the sidewalk and follow the rules?

Client: That’s weak brown-nosing bullshit.

Counselor: Then will you explore that with me? Are you strong enough to look very hard right now with me at what this being weak shit is all about?

Client: Yeah. I’m strong enough. What do you want me to do?

Counselor: Okay then. Let’s really get serious about this. Relax in your chair and imagine yourself walking on the grass and someone asks you to get on the sidewalk and then you just see yourself smiling and saying, “Oh yeah, sure.” And then you see yourself apologize. You say, “Sorry about that. My bad. You’re right. Thanks.” What does that bring up for you.

Client: Goddamn it! It just makes me feel like shit. Like I’m f-ing weak. I hate that.

In this counseling scenario the client is conceptualized as using expansive and angry behaviors to compensate for inner feelings of weakness and vulnerability. The counselor uses the client’s language to gently confront the discrepancy between what the client wants and her behaviors. As you can see from the preceding dialogue, this confrontation (and the counselor’s use of an interpersonal challenge) gets the client to look seriously at what her discrepant behavior is all about. This cooperation wouldn’t be possible without the earlier development of a therapy alliance . . . an alliance that seemed deepened by the fact that the client saw the counselor as another Brown Woman. After the confrontation and cooperation, the counselor shifts into a visualization activity designed to focus and vivify the client’s feelings. This process enabled the young Latina woman to begin understanding in greater depth why cooperating with rules triggered intense feelings of weakness. In addition, the client was able to begin articulating the meaning of feeling “weak” and how that meaning permeated and impacted her life.

To check out a 4+ minute existential counseling video clip go to: https://www.youtube.com/watch?v=jiirtIKcIeM

This clip is taken from our Counseling and Psychotherapy Theories 2 DVD set. The 2 DVD set is available through Psychotherapy.net: http://www.psychotherapy.net/video/counseling-psychotherapy-theories and Amazon: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1118402537/ref=asap_bc?ie=UTF8

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2 thoughts on “a short existential case example from counseling and psychotherapy theories . . .”.

Beautiful example of “process” work, staying with the client’s existential experience. Yes, it works.

Thanks Nadine! I hope all is well for you and your chickens:)

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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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Law School Case Briefs: Your Ultimate Guide

Last Updated: Aug 28, 2024

In U.S. law school, you’ll learn primarily by reviewing and discussing legal cases and opinions

Reviewing and analyzing a compilation of actual past legal cases and judicial opinions, or case law, is the primary manner of studying and learning law in U.S. law schools. This method of studying actual judicial opinions to learn legal rules and develop the ability to think like a lawyer is called the Case Method.

The actual compilation of past legal cases and opinions that you will use for a law school class is called a casebook. For many courses in law school, your casebook will be your only textbook. Case Briefs are simply a set of notes comprised of important points on each assigned case that you’ll use for class discussions.

The case brief is the end result of reading a case, re-reading it, taking it apart, and putting it back together again. In addition to being a useful tool for self-instruction and referencing, the case brief also provides a valuable “cheat sheet” for class participation. With a few techniques in hand, you will be able to master the art of briefing cases to be well on your way to owning class discussions.

You’ll also pull some information from your case briefs into outlines you’ll use to ultimately prepare for mid-terms and finals.

Useful beyond law school class prep

Learning to create a good case brief is extremely helpful well beyond participating in class. When you begin outlining and prepping for finals, you’ll find it easier and faster to reference your more concise case briefs vs. re-reading cases for a refresher.

In the future, when a client’s case requires legal research, you’ll be able to quickly examine dozens of cases to locate and document what you need in an organized and efficient manner. Case briefing is a skill worth honing.

Techniques for briefing a case

There are many ways to brief a case. You should find the format that is most useful for your class and exam preparation. Often, a case is misread because the student fails to break it down into its essential elements. Here are the main elements that are helpful to include:

Briefly state the name of the case and its parties, what happened factually and procedurally leading to the controversy, and the judgment. This information is necessary because legal principles are defined by the situations in which they arise, and a fact is legally relevant if it had an impact on the case’s outcome.

For example, in a personal injury action arising from a car accident, the color of the parties’ cars seldom would be relevant to the case’s outcome. Similarly, if the plaintiff and defendant presented different versions of the facts, you should describe those differences that are relevant to the court’s consideration of the case.

Trial court

State the trial court’s judgment or decision in the case. Did the court decide in favor of the plaintiff or the defendant? What remedy, if any, did the court grant?

State the issue or issues raised on appeal. This is where you will describe the opinion you are briefing. In this section of the brief, state the factual and legal questions that the court had to decide. To analyze a case properly, you want to break it down to its component parts. Be sure to stick to the relevant issue or issues, because these are the ones for which the court made a final decision and which are binding.

In a sentence or two, state the legal principle or the applied rule of law on which the court relied to reach its answer (the holding).

Describe why the court arrived at its holding. This section of the case brief may be the most important, because you must understand the court’s reasoning to be able to analyze it and apply it to other situations — such as those you will see on the bar exam and in real life scenarios when you are a practicing attorney.

Objective theory

Concurring and dissenting opinions can present an interesting alternative analysis or theory of the case. Therefore, you should describe the analysis in your case briefs. It will help you see the case in a different light.

The do's of case briefing

Use a roadmap for reading assignments

Before you start reading assigned cases, look at the chapter headings and the table of contents in the casebook. These will tell you the topic to which the assigned cases relate, and where this topic fits in the overall course.

Keep a good law dictionary close

Legal terminology is a technical language with technical meanings. When a word is used that you don’t understand, or when a word is used in some unusual sense, stop and look it up. Try to use that word in your case briefs so you’ll better recall the context and its meaning later.

Create your own briefing system

Briefing cases is core to learning to “think like a lawyer”. Once mastered, you’ll be able to efficiently distill facts and reasoning of a case. Try a format of breaking down the essential elements: Facts, Trial Court, Issue, Rule, Rationale and Objective Theory.

Keep your briefs brief

Your case briefs are there to help you quickly recall the case in sufficient detail during class discussion and to integrate into your class notes and outlines later. Regurgitating the entire case is not helpful. Avoid copying citations. Simply try to capture the gist of the facts and the court’s reasoning in just a few words.

Come to class prepared

You will be expected to come to class prepared to discuss assigned cases. That means learning how to read and brief those cases as efficiently as possible. You may not brief every case in every class throughout law school. Definitely brief cases until you’re good at it, which for most students means throughout 1L year.

Build case briefing time into your study routine

Time is a hot commodity in law school, and efficiency is key. Establishing a study routine that incorporates time to write case briefs will ensure that you prepare well for class and exams, from the very beginning. Briefing your cases throughout the year will ensure you are not only working hard but also smarter.

The don'ts of case briefing

Skip out on reading the actual case

Some law students attempt to save time by reading only a third-party case brief or another student’s hand-me-down outlines. While these can be helpful supplements, reading and analyzing the case is key to truly understanding and applying the information you are learning to other situations. This is what it means to think like a lawyer. Your professor also knows this is occurring and will change the question to things he or she knows are not in the case briefs.

Rely solely on book briefing

Book briefing, or simply highlighting information in different colors in your casebook, will not hardwire the material into your mind. Case briefs will. When you are just starting out, it will be difficult to understand and remember what you previously read without taking notes in some organized fashion — the final step of writing out a brief.

Copy holdings verbatim from the case

It’s important to state the holding (judgement in a case) in your own words as you brief. By doing so, you are more apt to fully understand the legal principles better and memorize them more easily.

Worry if your case briefs aren’t perfect

Most professors will promote the value of briefing but will never actually ask to see that you have, in fact, briefed. Remember, you are the person that the brief will serve, and briefing is a skill you will develop as you become more comfortable reading cases.

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Counselling Case Study: An Overwhelmed Client

Chris came to counselling because he was experiencing increasing feelings of being stressed, overwhelmed and weighed down by his commitments in life. He has been particularly concerned about his negative thoughts and attitude at work and at home and would like to change this. Chris has been seeing a Professional Counsellor for three sessions and together they have been using an eclectic approach using Cognitive Behavioural Therapy, some Solution Focused Therapy and Gestalt techniques. For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Chris is a husband of three years to Michelle and father to 18-month-old James. He is 45 years of age and a nurse at a local hospital. He has also been studying part time for his Masters degree in Nursing for three years. His wife is also a nurse and together they work shift-work in order to look after James. Chris states he enjoys his job but it can be demanding and physically tiring at times. He has previously enjoyed his studies but is now finding it difficult to finish the work with the responsibilities of a small baby. For financial reasons he has not been able to complete his studies full-time.

Chris has recently found the demands of being a husband, a nurse, a father and a student to be taxing on his physical and emotional health and he has found himself to be snappy, irritable, exhausted and unmotivated at home and at work. He has noticed that his relationship with his wife Michelle has become strained and he has begun to resent her for asking him to complete even minor chores around the home. He is feeling unloved and taken for granted by his wife. He has started questioning whether he wants to finish his studies and whether he wants to stay in the marriage.

Chris was prompted to come to counselling at the suggestion of his doctor. Chris presented to his doctor’s surgery complaining of an itchy rash covering his arms and torso, and of throbbing headaches at night and in the morning. Chris stated that medical tests revealed no physical reason for these complaints and his doctor suggested that working through some of the demands and pressures Chris had in his life may relieve the symptoms, as they may be directly related to stress and tension. Chris was happy to do this as he stated he was unhappy with his reactions and attitude at this time, as he had always been a happy, positive sort of guy.

Previous Sessions

In the first three sessions, C worked through identifying the above issues and asked Chris what he felt was the most important issue requiring attention. Chris identified this as his negative thought patterns and pessimistic way of looking at each day in the morning.

C worked to immediately change this by using Ellis’ Rational Emotive Behaviour Therapy ABC model. Using this framework to identify the behavioural and emotional consequences of his thought patterns, Chris chose to work on his attitude to going to work everyday. Before using the ABC model, Chris’ thoughts and behaviours looked like this:

A – Alarm rings every morning at 7am B – Chris says to self “Oh, no. I hate my job. This is going to be another horrible day” C – The behavioural consequence here is that Chris is often late for work because he procrastinates about going and then is often reprimanded by his supervisor. D – The emotional consequences are that Chris has a sense of despair about his ability as a nurse

After applying the ABC model to change his irrational beliefs (in B), Chris has found the following pattern when his alarm rings in the morning:

A – Alarm rings every morning at 7am B – Chris says to self “I can do this. Every day is a new day. I will work well today” C – The behavioural consequence has meant that Chris has not been late for work and therefore not in trouble from his supervisor – in fact he has been praised for his promptness in front of other staff (thus reinforcing his behaviour to be on time!)

D – The emotional consequences for Chris have included a greater sense of satisfaction with his work, a feeling of being appreciated at work, and more importantly, the knowledge and evidence that he is in control of his own thoughts.

Current Session Content

After Chris had noticed some considerable improvements in his thought processes and felt more in charge of his meditating thoughts about work, he and C moved onto discussing the feelings he was having about his studies and his marriage.

Chris had noticed that his more positive attitude at work had certainly influenced his mood at home, but something was still not right. He also noted that his rash and headaches in the morning had somewhat subsided, although he was still suffering throbbing pain in his temples at night after work. C began asking questions:

Extract, Counsellor and Client

Counsellor: “Chris, you talked in our first session about wanting to leave your marriage and maybe not finish your Masters, how do you feel about this now we have worked on your positive thinking?”

Client: “You know, as much as the positive thinking has helped with getting up each day and getting through work, I don’t know if it has changed my other feelings. I dunno, I still don’t know whether I want to finish my Masters. I mean, I feel better about my marriage, but I still find myself lying awake at night wondering at the “why” of everything. Know what I mean?”

C: “Tell me more about the “why”. Just your marriage and studies?”

Client: “Well, not really just that. I mean, I’m 45 now. I have a son and a wife and a job, but something just doesn’t seem right. Like maybe something’s missing.”

C: “Chris, can I just ask a question for a moment?”

Client: “Sure”.

C: “If I could wave a magic wand and you could wake up tomorrow and everything was worked out, everything was the way you wanted, what would it be like?”

Client: “It would be great!”

C: “Great, how?”

Client: “Well, I guess I would be happy. Everyday.”

C: “So would your marriage be any different? Your studies?”

Client: “Probably not. I mean, Michelle isn’t really asking more of me than when we first got together. It just seems more. The studies stay the same no matter how I feel.”

C: “So..?”

Client: “Oh, I get it. It’s not really the stuff is it? It’s me. I’m the one who has changed.”

C: “Is that how you feel?”

C proceeded to show Chris that while some things at home and work were the same as when they first married, other factors had changed. C wanted to make sure that Chris was not going to be too hard upon himself for realising that much of his own thoughts and feelings were under his own control. C pointed out elements of stress and how it works, and again they surveyed Chris’ life to examine the external factors.

Counsellor: “Chris, I just want to go back a step to the work we did around your thoughts and taking control”

Client: “Mmmmm…”

C: “Are you familiar with the word stress?”

Client: “Sure”

C: “I don’t just mean the bad form of stress, where you want to rip your hair out, but other forms too”

Client: “I’m confused”

C: “So am I! What I mean is, anything in your life that causes a change, causes stress. So when you find your dream wife and get married, this is stress. When you break your leg, this is stress. There are different types of stress, but mostly it is a word that means any change in your life.”

Client: “Ok. Where are we going?”

C: “When we look at your life and you say that things are still basically the same as when you married, you might be right on the surface, but underneath lots of things have changed that may have caused forms of stress.”

Client: “Ok”

C: “What if we have a look at exactly what is going on in your life right now and see if it makes more sense?”

C showed Chris a copy of the Holmes Rahe Stress Scale (available easily on the Internet for use – try www.teachhealth.com ) and together they identified different things that were in his life over the past 12 months, which he may not necessarily have thought of as forms of stress.

Some examples from the Holmes Rahe Scale which Chris identified included: a mortgage, change in the health of a family member (Chris disclosed that his mother had recently been diagnosed with cancer and he hadn’t really thought of this as playing an active role in the physical symptoms he was having), changes in his responsibilities at work, chronic allergies, and a change in the number of family get togethers (these had decreased due to Chris and his wife’s work and study commitments).

C helped Chris realise that there was a great deal going on in his life and that someone else in the same position may feel just as overwhelmed. This exercise served to help Chris acknowledge the forms of stress, understand how they impacted upon him and avoid falling into the trap of believing that he was the only one who had changed and everything was his fault.

Satisfied with Chris’ grasp on these concepts, C moved back to the issue of Chris being unsatisfied in life generally and searching for answers to the “why” of it all. Together they examined more closely what Chris was feeling and he surprised himself by breaking down and crying in one of these sessions. Chris talked about his own upbringing and not feeling that he had ever been good enough for his father, who had since passed away.

He discussed that his father had been a Doctor and had wanted Chris to follow the same. Chris’ grades had prevented him from achieving this and so he had chosen nursing as the next best thing. Chris was surprised at this realisation as he and C explored this issue, and he then started to examine whether nursing was really his chosen profession. C used a visual technique to examine this and coupled it with the Gestalt technique of using an empty chair because Chris’ father had died, in order to give Chris a chance to express his thoughts and feelings.

Extracts include:

Client: “I think what it means is that somewhere I knew I was never going to be as good as him and nursing was a bit of a cop out too. Even though I didn’t get the grades to get into medicine.”

C: “Would it be possible that you may have subconsciously manipulated the situation to avoid the scrutiny or pressure of studying medicine and being a doctor?”

Client: “Yeah, you know I think that’s it. It all adds up. I mean, I like nursing, but I think I’ve always felt there was something more that I didn’t achieve, for some reason.”

C: “We call it self-sabotaging, where subconsciously a person might do the very thing they are avoiding or vice versa.”

Client: “How bizarre.”

C: ‘Would it be ok if we explored your choice of nursing further with a visual exercise?”

Client: “Sure. Whatever works.”

C asked Chris to close his eyes and using a brief relaxation technique they had employed in the earlier sessions using CBT, C asked Chris to imagine the first day he had started work as a Nurse, after graduating. C specifically asked Chris to watch the scenario as it unfolded, from an outsider’s point of view. C did not want Chris to be drawn into the scene, but wanted him to be able to note his own feelings and behaviours from a distance.

Client: “I can remember it like it was yesterday. It was such a busy day and I had no idea what I was doing.”

C: “Chris, can you imagine yourself somewhere in the middle of the day, with things happening around you?”

Client: “Yep, there was this patient who was crying in the waiting room and I went over to help.”

C: “You seem a little sad.”

Client: “Well, she was waiting for her child who was in emergency. I think there was an accident or something. It was so hard to sit there and just watch, waiting you know.”

C: “Run the scene before you until you get to the end of that situation. Watch yourself handle it.”

Client: “I know I look helpless but in the end, she came and thanked me for just being there. Her daughter was alright.”

C: “That’s a smile.”

Client: “Well, it was such a good feeling on that day because in the middle of all the chaos, I sat with her and just kinda talked about stuff, to take her mind off it, and she thanked me in the end. I really felt like I did nothing.”

C: “But as you watch now…”

Client: “I think it felt good. When I see myself now, I know I handled it ok, for the first day and all, and I guess I felt I could make it.”

Chris noted that in that moment of starting work after his studies, he felt okay as a nurse. This helped him clarify that while he was not a doctor, his work was appreciated and valued as a nurse. Together he and C explored the notion of still becoming a doctor, but Chris said he felt secure in his current role. He noticed over the next few sessions since this realisation, that his feelings at work continued to improve, and that he felt happier and more valued as a staff member; and that his patients benefited from this. Despite the progress Chris had made with these feelings, it still left the issue of his unresolved feelings towards his father.

Through more discussion, Chris came to realise that the unresolved childhood event of not feeling as though he had lived up to his Father’s expectations, was still having an impact on his feelings of emptiness and unfulfilment. C explained the concept of the Empty Chair technique to Chris and he agreed to give it a try, although he was finding it difficult to put his feelings towards his father into words. As a brief explanation, here the client is asked to put feelings or thoughts into action.

For example, C encouraged Chris to use a kind of role playing (in this case, speaking to an empty chair because Chris’ father was not present). He was encouraged to tell his father how he felt about the expectations he felt as a child. Enactment here is intended as a way of increasing awareness, not as a form of catharsis and in the case of Chris he had difficulty expressing his feelings into words in front of C. Instead of badgering Chris to continue, C took a step back and changed the angle slightly and tried some integrating and body techniques.

Integrating techniques bring together processes the patient doesn’t bring together or actively keeps apart (splitting). The client might be asked to put words to a negative process, such as tensing, crying or twitching. Or when the client verbally reports a feeling, that is, an emotion, they might be asked to locate it in their body.

Another example is asking a client to express positive and negative feelings about the same person. The body techniques include any technique that brings clients’ awareness to their body functioning or helps them to be aware of how they can use their bodies to support excitement, awareness and contact. In this case C observed Chris sitting tightly and rigidly in the chair after trying to express his feelings to his father in the Empty Chair technique.

C: “Would you be willing to try another experiment?”

Client: Nods

C: “Take some deep, deep breaths and each time you exhale, let your jaw loosely move down.”

Client: Breathes deeply, lets jaw drop on the exhale

C: “Stay with it”

Client: Starts melting, crying, then sobbing

At this point Chris was more able to speak about his feelings and loudly started to express how he hated his father, and how angry he was. C let Chris vent his feelings, which had been suppressed for many years. This was a huge breakthrough for Chris, even more so because this issue had not been foremost in his mind when he entered counselling.

This powerful technique involving role-playing may sound artificial and might make some people feel self-conscious as it did for Chris in the beginning, but it can be a powerful way to approach buried feelings and gain new insight into them. While Chris still had some way to go in working through these feelings, this session was useful for him to open to the idea of working on self-awareness.

Session Summary

In summary, Chris’ counselling focused on a number of issues:

• His initial complaint of negative thought patterns and pessimistic attitude to work and life
• The number of stressors in Chris’ life
• His feeling of being empty and unfulfilled in life which expanded into the issues of not living up to his father’s expectations and sacrificing a medical career

The techniques of CBT helped Chris rapidly get a hold on his negative thought patterns and he was able to implement these in his life quite quickly. Visualisation techniques helped Chris explore his notion that perhaps he still wanted to be a doctor instead of a nurse. Finally, Gestalt techniques helped Chris begin to understand his unresolved feelings towards his father.

After the session involving the Gestalt technique of the empty chair, Chris opted to change his weekly sessions to fortnightly for 2 sessions, and then visited monthly for two more sessions. He stated at this time that life had settled back down to “normal”, meaning that he was coping well at work, had mapped out a timetable to finish his nursing studies and that his marriage was happy. He discussed that Michelle constantly pointed out the positive changes in him and this made him feel even more in control of his feelings, thoughts and behaviours.

Chris stated that the feelings of anger and resentment towards his father had subsided although he found himself pondering his childhood a little more now than he used too. He said that the counselling had worked to a degree with this issue, but because he had not realised it when he came into counselling, he was still coming to terms with his feelings.

He and C discussed this being a normal phenomenon, and the notion that if in the future the issue proved too difficult to handle, or started to again interfere in Chris’ life, then future sessions might be necessary. Chris described that he was particularly positive about his future, about spending more time with his son and wife, and felt more in control than he had ever been before.

Author: Peta Hartmann

Related Case Studies: A Case of Stressful Life Change , A Case of Low Self Esteem , A Case of Using a Person-Centred and Cognitive-Behavioural Approach to Burnout

• June 1, 2007
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• ABC Model , Case Study , REBT , Stress
• Case Studies , Relationship & Families , Stress Management

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