The case conceptualization (sometimes called a case formulation) is the clinician’s collective understanding of the client’s problems as viewed through a particular theoretical orientation; as defined by the biological, psychological, and social contexts of the client; and as supported by a body of research and practice that links a set of co‐occurring symptoms to a diagnosis and, ultimately, a treatment plan. A strong case conceptualization is guided by the utilization of a theoretical orientation that provides a framework for the clinician from which to condense and synthesize multiple pieces of information into a coherent and well‐developed narrative. This narrative aims to identify not only the precipitating cause(s) of the client’s problems, but also the forces at work, both internal and external to the client, that serve to maintain the problems. Formal research on case conceptualization is in the nascent stage.

SAMPLE—PLEASE CONSULT YOUR SITE SUPERVISOR AND UNIVERSITY SUPERVISOR FOR APPROPRIATE FORM

Session Write-Up

(Case Conceptualization)

Conducting counseling sessions with the support and feedback of others is an important part of a trainee’s professional development.  In most training programs sessions are recorded on either audio or video tape.  Once a session is completed, the trainee listens to the recording, providing him/herself with feedback that can lead to ideas for future sessions and recognition of areas in which one’s work can be improved.  Advanced counselors, as well as trainees, listen to develop a full picture of what happened in the session:  important client emotions, beliefs, and personality characteristics not fully seen during the actual session, significant moments or turning points, and significant things the counselor did or did not do.   Receiving organized feedback from the supervisor and giving organized feedback to oneself are major vehicles both for improving one’s work with a given client and for building one’s professional skills.

The following outline is offered as an aid to producing a written analysis of a counseling session, especially one that has been recorded.  Used carefully, the outline can help the trainee organize thoughts about the client, the session, and the quality of one’s work. Assignment: Case Conceptualization

Background information

Demographic information, such as age, grade in school, employment, family unit, and history that seems relevant to the presenting problem.

Presenting problem:  Why did the client approach you, from the client’s perspective?  Or why did you approach the client?

Was there a precipitating set of circumstances?  How long has the problem(s) persisted?

If third parties are involved, what were their observations and concerns?

Overview of the session

What did you talk about?

What were the dominant issues and themes for this session?

If this was a session beyond the initial meeting, what were your process and outcome goals going into the session?

Observations and assessment:  Conceptualization of Problem

Describe your observations and impressions of the client?

What is your view of the problem?  What are the common themes?

What are the client’s barriers to growth and coping skills?

What is the etiology of the client’s present psychological capacity or incapacity?

What is she/he trying to accomplish by various behaviors?

What are your counseling goals?

Observations about self

Describe significant themes and patterns you observed in your own behavior, noting what you did that you considered especially effective and areas that were troublesome for you.

Describe your own internal experiencing during the session, with special focus on times or places where you felt confused, tense, angry, or at a loss.

Plans for the next session

How do you hope to follow up in subsequent sessions?

What issues and concerns do you think worthwhile to explore?

What process goals will you try to accomplish?

Help

Specifically what kind of help would you like, either from your practicum supervisor or from fellow students, about this client, this session, and your helping efforts? Assignment: Case Conceptualization