Guidelines for Case Conceptualization

Guidelines for Case Conceptualization

For each case study you will need to address the following information.  You do not need to cite your work.

1. Background Information

The first section of your paper will present your client’s background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals and coping skills and weaknesses. Avoid copying the material presented in the case study. Rather, present your understanding of the client. Identify patterns of behavior that lead to a specific problem.

2. Description of the Presenting Problem

In the next section of your case study, you will describe the problem or symptoms that the client presented with. Describe any physical, emotional or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Most importantly you should clearly state how symptoms have impaired the functioning of the client.  Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

3. Your Diagnosis

Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the clients symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis. Also, you may need to indicate why another similar diagnosis is not appropriate.

4. Intervention

The last section of your paper will focus on the intervention(s) used to help the client. Your intervention should be effective for the diagnosis you have made. You may modify treatment approaches to work with the client but, be clear in your description.

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