General Structure of the Case Reports

Although not every report will follow the same structure, the following points illustrate the main sections that need to be attended to in any Case Report. It is important to be consistent in writing style and it is generally considered good practice to write in the past tense throughout. The first and third person may be used when referring to yourself, along with a footnote to explain your choice. The publication manual of the American Psychological Association is a useful reference point. If figures/tables are used to illustrate material, these must have a clear legend and be referenced in the text (e.g. Figure 1 shows…). The report must have page numbers throughout.

a. Front sheet. The Clinical Case Report should be accompanied by a front sheet on which is marked: The title; the page count (maximum 16 pages); a statement about confidentiality/anonymity/client consent; your University Registration Number (URN) to enable anonymised marking to be undertaken. Remember, if you use running headers or footnotes, do not include identifying material! The title should provide the reader with information regarding the client, their gender, their approximate age, the assessment and/or intervention and the nature of the problem. This will also be helpful in providing the external examiners with an overview of the Case Reports presented in the Clinical Portfolio.

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b. Contents page. Each Case Report should include a contents page that covers the main sections and sub-sections of the Case Report with page numbers of the sections. The contents page should list the Appendices, with their titles and page numbers. c. Referral of the problem. This should contain a clear and concise account of the

problem for which the client was referred to the service in question. This includes brief details about the client, details about the referral route into the service (e.g. GP referral letter; telephone call to supervisor asking for an assessment to be carried out) and a brief summary of the identified difficulty/issue. Please always ensure there is a letter of referral attached to the case report as an Appendix. A copy of an email referral letter is acceptable. If there is further written correspondence about the referral, this should be included in an Appendix.

d. Diversity. Both during the therapeutic process and when writing up a case report, the issues relating to diversity need to be addressed. These could include for example, age, gender, culture, class, ethnicity, disability, sexual orientation and religious faith and how they impact on people’s lives. You are reminded that references to diversity need to include an awareness of what you yourself bring to the assessment, formulation and therapeutic process by virtue of your own characteristics and experience. An acknowledgement of the ethnic background and first language of the client/family/carers should be made here, even if the client is from a majority ethnic culture. A Venn diagram can be used to summarise areas of similarity and difference between yourself and the client.

e. Presenting problem. A clear and concise description of the identified problem(s) should be outlined here. This should include how the client (individual, couple, family, group, staff team, etc.), their family or carers and other involved professionals (as appropriate) viewed the problem. If the work described is within a particular context, for instance a group home or day hospital, it is necessary to say how staff viewed the problem and how they see the solution. The initial perception of the problem as seen by you might be described here. Clearly the reason for referral, or problem, may change in the light of new information gleaned, and new experiences. This can be acknowledged here, and the reader told where in the report it will be discussed further.

f. Initial assessment of the problem. This should include the following subsections: i. The assessment process. A brief summary at the start of this section should

inform the reader about the assessment work that was carried out. This includes the number of sessions taken to complete the initial assessment and whether the work was carried out independently or jointly with another person (e.g. the Clinical Supervisor, the team psychiatrist, the co-facilitator of a group). If there were particular practical or ethical difficulties or issues that made gaining contact with the client or staff group problematic then this should be included here. This might involve consideration about the initial process of engagement with the client, the development of the therapeutic relationship, or any particular observations surrounding the way the client/family/carers presented during the assessment. In addition this section

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should include discussion of how you engaged with the professional network and negotiated your position in relation to the work undertaken.

ii. Sources of information used for the assessment. This will include information gathered from various sources and should comment on:

1. Structured/unstructured face-to-face interviews with clients, carers, staff etc.

2. Case notes (e.g. medical or previous psychology records); 3. Telephone conversations;

4. Team meetings (e.g. CMHT or Family Therapy Team discussions) or liaison with other professionals (e.g. Child Protection Team);

5. Observations (e.g. watching a child at play with siblings in their family home).

iii. Risk assessment. The risk assessment procedure must be outlined here. This section should include information regarding the evidence supporting your assessment and how you ensured that risk was monitored and reviewed, both to the client and to others. You should describe what the particular risks were to the client and others, under what circumstances these would arise/increase/decrease, and what steps were taken to minimise these risks. iv. Background history. This section provides a context for the clinical work and

should usually include:

1. The history, context and development of the presenting problem(s). This should give an account of previous treatment(s) or accounts by the client (and relevant others) of how they have tried to solve their problem before;

2. Details of the client’s family, educational and occupational history as appropriate. Details of their relationships, which might include marital history or relationship with significant other(s) such as parents or carers. It is strongly recommended that this information be shown in a genogram. Information pertinent to the understanding of the particular problem must be included, such as impact on their relationships, and impact of relationships on the “problem”.

3. A clear developmental history as appropriate;

4. Details about the individuals assessed for Group Work;

5. Information about the particular context/setting for the work if this is appropriate (e.g. if assessing a child's behavioural problems at home and school; the assessment of behaviour challenging to staff in a group home; indirect work with staff to inform a client's inpatient

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care plans). An ecomap is recommended to summarise the relationships within the professional network.

v. Initial investigations. This section should provide the reader with a clear account of how you used particular measures or procedures to explore the problem in more detail. This might involve for instance one or more of the following:

1. Questionnaire measures (e.g. BDI-II, BAI, EATS etc.); 2. Psychometric assessment (e.g. WAIS-IV, WMS-IV etc.);

3. Participant or non-participant observation of the individual or setting; 4. Daily mood or activity diaries;

5. Structured interviews with clients, carers, professionals.

A brief description of the instrument that was administered, together with details about validity and reliability, must always be given. If the work involves detailed observational work, this should be outlined here, or if you asked the client/family/care team to keep particular records, this should be described. It is essential that the rationale for using a particular assessment tool is always given and that there is a clear interpretation of the results. This section should usually form the basis for how the intervention phase is to be evaluated. Baseline data should be included for all interventions, no matter what the particular model of therapy or intervention. The assessment (combined with formulation) should therefore provide the data against which outcome will be judged. The Appendices should include anonymised copies of record or diary sheets.

vi. The development of the therapeutic relationship. Give an account of the development of the therapeutic relationship and/or working alliance and what factors and experiences helped to sustain it or challenge it. It is important to reference the impact of difference and diversity here.

g. Initial Formulation. This section is central to the report and allows you to demonstrate how you understood the problem in social and psychological terms following the assessment phase. In the context of collaborative practice, indicate how your client (and relevant others) understood and contributed to the formulation. The initial formulation is an attempt to answer the following questions:

i. Why has this person/family/group of people been referred now (precipitating factors)?

ii. How can the problem be accounted for (origin)?

iii. What is keeping the problem going (maintenance), including relational, social, economic and other cultural factors? What are the exceptions to the problem? What solutions have been tried?

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iv. What interventions should be considered based on the client presentation (e.g. motivation), psychological formulation and evidence base (e.g. research evidence on trials of CBT for OCD)? What is the role of the therapeutic relationship in enabling the work?

v. How have you shown an appreciation of diversity and cultural difference in the formulation? What is the impact?

The information presented in the assessment section of the report should allow you to make some clear hypotheses about what is happening for this client(s). Usually it is helpful to present the formulation in diagrammatic form. A formulation is really a series of hypotheses based upon psychological and psychotherapy theories and the research base relevant for the case. This might include for example, literature surrounding divorce and studies that have attempted to evaluate a particular intervention for children whose parents have divorced. You must, however, demonstrate how the literature relates to this particular client (theory-practice links). An initial psychological formulation does not have to be correct but must be clearly related to an evidence base. Furthermore, a formulation must form the basis of the planned clinical work. Remember also to include an appreciation and acknowledgement of the role of supervision in the development of a formulation and intervention.

If the work carried out is an extended assessment, the formulation should show how you understand the presenting difficulties at this early stage, and provide a rationale for the extended assessment. Examples might include: a theoretical discussion of dementia and the rationale for extended psychometric testing; issues surrounding risk within the context of a client's presenting problem and the rationale for further risk assessment work, e.g. when working with self harming behaviour, or domestic violence.

h. Action Plan. This should follow logically from the Initial Assessment of the Problem and the Formulation. The Action Plan might involve further detailed assessment (if the case study is to be an “extended assessment” and/or an outline of the Intervention. It should detail the rationale for the approach taken and wherever possible this should be supported by research evidence. If a piece of work is planned that actually contravenes current empirical evidence, you would need to give a very sound rationale indeed to justify the particular course of action you planned to take. Some useful questions to try to answer might be:

i. On what basis did I/we decide to take a particular course of action? Was the decision collaborative? Who was involved? What was my supervisor’s contribution?

ii. What did I/we hope to achieve through undertaking this particular Intervention?

iii. What methods did I/we choose so as to meet these aims, and why? Was this collaborative?

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iv. Have I/we been clear about what exactly I planned to offer the client/family/staff group? What choice, if any, was offered to them? What are the ethical issues involved?

v. Have I/we been clear about their contribution to the plan and their views of the plan?

vi. Am I/we clear about what change will “look like” for everyone involved and its meaning for the client/family/staff group?

This is a useful section in which to consider any ethical or professional issues that have been raised as a result of the assessment and formulation. An example might be a consideration of the dilemmas attached to intervening or not intervening with a client whose behaviour challenges the resources of a staff group. This could be in the context of a referral from an understaffed and under-resourced group home (as highlighted from the assessment). An associated plan of action would follow as a result of these dilemmas.

i. Intervention. Potentially, a lot of information may need to be summarised in this section (e.g. 18 sessions of psychodynamic work). Sometimes the Action Plan will help you to structure this section, particularly if it detailed several different pieces of work. It is worth planning this section carefully and considering how best to inform the reader about what happened. For instance, for a long therapeutic intervention, think about breaking this section down into the main phases of the work (e.g. beginning, middle and end) or consider summarising the key themes that emerged (e.g. Grieving for a lost parent; rejection by the therapist). This section can address the following:

i. The intervention process. A brief summary at the start of this section should inform the reader about the intervention work that was carried out. This includes the number of sessions taken to complete the intervention and whether the work was carried out independently or jointly with another person. If a contract was agreed, this should be reported here. If the work did not go according to the plan, this must be summarised here. Perhaps there were particular difficulties or issues that made the intervention problematic, for instance the client's attendance at sessions or difficulties in the therapeutic relationship, and how they were addressed. Any professional or ethical issues arising from the case should also be summarised here, for instance child or adult protection issues that led you to veer away from the intended intervention.

ii. Content versus process. A good write-up of an intervention section achieves a good balance between content and process. It must allow the reader to understand the clinical work that was carried out, including the procedures followed and the skills/techniques that were demonstrated by you. It should not, however, be a blow by blow account of the work. The intervention section also needs to demonstrate your clinical competence (i.e. how were the

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sessions conducted and how did the Intervention relate to the Formulation and Action Plan?).

iii. Examples from the clinical work. It is helpful to illustrate this section with examples from the work. For instance, highlighting the application of a particular skill/technique or illustrating a particular phase of the work. This may take the form of a short transcript from the therapy.

iv. Further assessment work. Any further assessment work that is carried out during the intervention phase must be clearly presented, with a rationale for undertaking the further assessment work clearly set out. In systemic work, formulation is ongoing, in the light of feedback. This process can be described here. This is particularly important if the need for further assessment was not highlighted previously in the Formulation and Action Plan sections. Data must always be interpreted and examples of record forms included in Appendices.

v. Theory-practice links. It is important to continue demonstrating links between theory and practice in the intervention section, relating procedures followed to established research/ evidence base.

j. Outcome and follow-up. Outcome should never be introduced as a new idea at this stage of the Case Report. The framework for how the clinical work was to be evaluated should have been introduced as part of the initial assessment or action plan. Give an account of the ending of the work, and how everyone involved planned it and managed it.

If there has been time on placement to offer a follow-up, then include this in your account of the outcome. If you plan to return to do a follow-up, or this is to be carried out by another team member or your supervisor, it is helpful to give details about this and how change can be evaluated at that point. Some consideration of maintenance of change for the future should be considered here. For instance, will any change be maintained over time and what factors may help or hinder this process?

If the Case Report is an extended assessment or a psychometric assessment, make it very clear how the recommendations will be implemented, by whom, and who will monitor them. In addition, make it clear how feedback is given to clients.

This section must consider what has been achieved and accounts of change might include:

i. Descriptions and/or measures of change in relational and psychological functioning;

ii. Development of new skills in the client/s; iii. Behavioural observations;

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iv. Changes in the client’/s’ relationships and/or within the setting/context of the client’/s' life;

v. Changes in management/staff practice;

vi. Effectiveness of a teaching programme or group; vii. Description of change from the client’/s perspective; viii. Details of change as illustrated by diary records;

ix. Evaluation of client/s rating scales;

x. Description of change from your perspective as a trainee and the impact of the work on your development;

xi. Description of change from the perspective of other professionals/family members/carers.

Wherever possible, objective outcome measures that provide a good pre-intervention baseline, should be used to help evaluate the work. For instance, in the case of a treatment intervention, pre, interim and post administration of a depression inventory, summarised for the reader in a Table, could be presented here. Once again, all data must be interpreted within the text.

k. Reformulation of the problem. This section, together with the Critical Evaluation below, is an opportunity to reflect upon, and illustrate, what has been learned from the clinical work.

i. Is it necessary to always reformulate? Over the course of any clinical work, new information emerges that should be used to substantiate or change particular aspects of an Initial Formulation. For instance, which hypotheses were supported by the work? Which ones were ruled out? What further hypotheses emerged as a result of the clinical work? Sometimes, the Initial Formulation can be shown to stand. It is not enough to simply state this as