Reporting in Counselling and Psychotherapy

A Trainee's Guide to Preparing Case Studies and Reports

Linda Papadopoulos, Malcolm Cross, Robert Bor

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9781138168725
• eBook ISBN: 9781134573899
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Trainee therapists need to show practical competence through the production of client reports and case studies. Reporting in Counselling and Psychotherapy is a unique hands-on guide to this element of practical work. Using clinical examples to guide the reader, and a detailed analysis of case study and process report writing, it will show how to present clear, concise and properly presented reports. The book will be an invaluable tool, not only for those embarking on practical training in psychotherapy, counselling and psychology, but also for trainers in these areas and for clinicians writing clinical reports or case presentations.

Chapter 1
Introduction

Although teaching methods in psychology and counselling may change and new theories emerge one thing that stays relatively constant is students’ anxiety about the assessment of their practical and clinical work. In many ways, the training of therapists is a relatively new academic strain and as such there is a dearth of practical academic literature in field. In order to qualify as a registered or accredited therapist, trainees have to complete a certain number of practice hours with a range of client groups. Practical competence in these clinical placements is usually assessed through the production of client process reports and case studies. Unfortunately, relatively little guidance is given to trainees about what is expected of them when writing client reports, and this can be a further source of anxiety for students who are already feeling insecure about their emerging competencies.

We hope that this text will help to remedy these problems. We have set about providing a detailed analysis of case-study and process-report writing in the field of professional therapy training. This book is intended for all those currently in, or embarking upon, practical training in psychotherapy, counselling and psychology. It is also intended to serve as a guide for trainers in these areas and for clinicians who face the prospect of writing clinical reports or preparing case presentations.

In the following few chapters we examine both the practical aspects of developing a competent and integrated client report and the theoretical positions and structure required in order to help students express their ideas creatively and coherently. We begin in Chapter 1 by deconstructing the various parts of case studies and process reports and discussing in detail a range of topics such as selecting case material and structuring case studies. Chapters 2 to 18 are examples of real case studies and process reports written by trainees at different stages of their professional development. They reflect different levels of developing competence among trainee therapists and encompass a wide variety of theoretical models applied to work involving different presenting problems. Each colleague who contributed a chapter to the book was asked to describe their thoughts about revisiting their case material months, or in some cases years, later. These accounts are genuine and illuminating. These cases serve to ground the reports both in terms of psychological process and professional tdevelopment. While reading these accounts it may be helpful for the reader to pay attention to the views expressed by the authors, their frank admission of insecurities and idiosyncrasies and, most of all, their ability to reflect upon their own process.

Each of the cases presented in the book begins with a brief editorial introduction. We describe why we chose each particular case, what we see as its merits and, in some cases, even its shortcomings. Our analysis in these sections is not intended to serve as a critical assessment of the reports but rather to highlight the most pertinent and salient aspects of client reports that trainers and clinicians look for.

In Chapter 19 we turn our attention to what NOT to do when writing a client report. This chapter aims to provide an informative account of where case material written up as coursework can go wrong. Our analysis here is not intended to be critical of trainees’ efforts but rather to highlight how easy it is to ‘miss the mark’ when trying to put one’s point across. In each case, practical suggestions and advice are given on how to rectify problem areas.

The final chapter is devoted to a summary of the work we have presented in the book. We discuss the main lessons that our students have taught us over the years and make our final recommendations on how to write a good case report.

We hope you get as much enjoyment and knowledge from reading this as we have had compiling it. Good luck with your own work in this area.

Case studies

The principle aim of a client case study is to allow the therapist to exhibit the link between practice and theory. It takes the form of a written summary of the principle aspects of the interaction between the counsellor and the client over a number of therapy sessions. A good case study will be represented by a careful and sensitive integration of clinical practice and theory rather than a simple verbatim description of therapy sessions. Therapists will write case studies at several points in their career and for different reasons. Some will do so for training purposes, others for clinical presentations and yet others as a means of justifying assessment or treatment. Trainees often need to create client case studies in order to demonstrate professional clinical competence whereas an experienced therapist may write a study for teaching or training purposes or for an academic text.

This section looks at:

• The details that need to be included in the case study.
• How to choose a case to present.
• How to structure and present a case study.
• How to prepare a case study.

One of the first and most important things to know about case studies is that they can vary from course to course and from practitioner to practitioner but there are common themes which link them. The aim of a case study is not to give a simple case history of the client but to give the reader a clear and concise account of the therapist’s ability to select and apply theoretical concepts in practice. It will also serve as an account of the therapist’s clinical skill and judgement.

The overall theme behind all case studies is the illustration of the integration of theory and clinical practice. This will require the therapist to illustrate how their choice of intervention was guided by a coherent theory of psychological change and explain the way in which that theory helped the therapist to understand the case. It is important that case studies show:

• A good understanding of the psychological principles of the chosen orientation.
• A level of synergy between this theoretical approach and the actual work with the client.

With respect to the preparation of a case study, it is crucial that the therapist has clearly defined criteria for the case study so that a specific purpose is outlined.

Theoretical position

It is important that the therapist has established a coherent theory, which can be clearly and concisely described to the reader. One of the main problems with writing case studies is that the therapist has a limited space within which to allow the reader to understand the case and the principles of the therapist’s approach. As Bor and Watts (1999) point out, most case studies used in the training arena tend to be between 1,000 and 3,000 words, but students often have great difficulty in staying within these limits. In this respect, it is important to remember that the purpose of the case study is not to show everything that has happened in the therapy sessions but to provide a concise summary, with appropriate examples of therapeutic interaction, that illustrates the case that the therapist is making. A useful way of approaching the writing of a case study is to prepare a summary of the core theoretical principles of the approach used. This summary can be altered if the therapist moves to a more integrated approach as therapy proceeds. Bor and Watts (1999) point out that it is important that the therapist tries to avoid submitting case studies that are based on commonsense principles, which most therapists tend to share. These can take the form of ‘listening to what client’s say’ or ‘structuring the session to allow adequate time’. The example that follows gives an illustration of the theoretical summary that might be appropriate for a person-centered approach to a therapy session:

Due to the work of Carl Rogers (1990), person-centered therapists believe that there are conditions that are not only necessary but sufficient to bring about therapeutic change. By sufficient, this approach means that the conditions will allow the client to self-actualise at the cost of other drives such as the drive to protect and defend their self-concept. The three qualities that Rogers emphasised were unconditional positive regard, empathy and genuineness on the part of the therapist. He noted that person-centered therapy was really a special type of interpersonal relationship between the client and the therapist and that it is this relationship that helps the client to move on. Although other traditions of therapy also emphasise the importance of these three tenets of person- centered therapy, they only see them as part of the establishment of a therapeutic environment in which to implement other treatments (such as cognitive behavioural therapy) rather than as sufficient for therapeutic change on their own.

This summary of the therapist’s theoretical orientation should be clear, concise and cover the essential and basic tenets of the approach. It should also include full references.

Which case to illustrate

The most important decision facing any therapist creating a case study is that of which case study to select. Although it may appear to be mere common sense, it is important to establish the grounds on which certain cases may be suitable or unsuitable. First, it is important to know exactly to whom the case is being presented. In deciding which cases to present, therapists must look at cases which give a clear idea of which approach to therapy was being used and show that this particular approach was maintained throughout the course of the therapy. The choice of case should be amenable to the specific therapeutic approach used and should exhibit the core theoretical principle of this approach. The case that the therapist chooses to present in the study should highlight the use of some of the methods specific to the theoretical approach rather than only using approaches that are generic to multiple psychotherapies. It is always useful for the therapist to explain what led them to the use of the particular therapeutic tradition. When the therapist has decided on an approach to represent in the case study it is essential that the study is consistent with this therapeutic approach.

It is also important that the chosen case highlights the issues that the therapist wishes to illustrate in the case study. As such, a case that is particularly difficult may not be suitable for a case-study approach where the therapist’s task is to highlight the use of case studies in a training context or where the therapist has limited text space. Under such circumstances, the case should be the right length so that there are sufficient sessions discussed to provide a detailed picture of the case without too much material being presented. It is important to be aware that it can be easy to overwhelm the reader with the details of the case, and a fine balance has to be reached where rich detail can be included but not to the detriment of the reader’s comprehension of the case.

Finally, it is important to remember that seeking and using help from other practitioners is an essential part of safe and effective professional practice and any use of supervision should be appropriately documented within the case study. This can help to highlight the effectiveness of supervision in a case context.

Case studies should highlight learning on behalf of the therapist but within the specific paradigm used. The main utilisation of a case study will be to enable other professionals to monitor and comprehend the process within a given context.

The presentation of the case study

As with other pieces of structured writing, a case study should exhibit a discernable introduction, middle and end. This structure will allow the reader to get the most out of the given study. Bor and Watts (1999) suggest the following guidelines for headings and sections for trainee counselling psychologists and these suggestions provide a good general template:

1 Introduction and start of the therapy.

• Introduction.
• Summary of theoretical orientation.
• The context of the work.
• The referral.
• Convening the first session.
• The presenting problem.
• Initial assessment and formulation of the problem.
• Negotiating a contract and therapeutic aims.
• Summary of biographical details of client and genogram.

2 The development of the therapy.

• The pattern of therapy.
• The therapeutic plan and main techniques used.
• Key content issues.
• The therapeutic process.
• Difficulties in the work.
• Making use of supervision.
• Changes in the formulation and the therapeutic plan.
• Changes in the therapeutic process over time.

3 The conclusion of the therapy.

• The therapeutic ending.
• Evaluation of the work.
• Arrangements for follow-up.
• Liaison with other professionals.
• What you learnt about psychotherapeutic practice and theory.
• Learning from the case about yourself as therapist.

4 References.

This guide is broad and may need to be amended in line with the therapist’s theoretical approach. With respect to the actual practicalities of creating the case study, it is recommended that the therapist gathers the following as source data for the write-up:

• Copies of notes from sessions.
• Supervision notes.
• Client biographical data.
• Referral letters.
• Any subsequent reports on the client that the therapist may have compiled.
• Consent form from the client, giving permission for the trainee to use the work.

Genograms (family trees) can be extremely useful tools, both in the therapeutic context and during the preparation of a case study. They act as brief summaries of essential client data that can be presented in such a concise fashion that more space is made available to comment on other aspects of the case. Finally, when approaching the stage of writing the study, the therapist needs to focus on the following three points:

• Emphasise the way that the given evidence explains the work.
• Emphasise patterns and processes rather than just descriptive details.
• Mention key stages in the therapeutic process where various options were available to the therapist. Discuss why certain avenues of enquiry were followed at the expense of others.

Bor and Watts (1999) point out that the careful use of evidence will help the therapist avoid stereotyping and making unfounded claims and over-generalisations. An example might be, ‘Like most children whose parents are going through a divorce, James felt that he was partly responsible’.

This would be inappropriate for two reasons. First, little meaning can be attached to such a generalisation without any supporting evidence and, second, there is no information suggesting that this is James’ experience. As such, this aspect of James’ feelings could be due to guesswork only on the part of the therapist.

One of the crucial, and easily overlooked, tenets of writing a case study concerns an emphasis on why the therapist worked as they did rather than merely reporting what they actually did. The therapist needs to document their reasons for taking certain paths of enquiry or interventions based on sound theoretical grounds. This point should be borne in mind at all stages of the case study.

Process reports

As a therapist, it is not only the words that are spoken in a session that hold import for the client. Of equal importance is the way in which those words are said, why those words were used, the issues that are not mentioned, the body language of the client and general non-verbal communication. These are all crucial determinants of any therapeutic session and form the process of the session, that is what actually happens in the therapy. A process report is a written meta-account of the communication and techniques that the therapist used in the therapeutic encounter. It portrays the methodology used by the therapist and highlights the therapist’s post- hoc views about the influence that their behaviour had on their client and on the relationship...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of Illustrations
• About the Editors
• Chapter 1: Introduction
• Chapter 2: A First Session Using the Systemic Approach
• Chapter 3: CBT As Applied to Anxiety: A Process Report
• Chapter 4: Achieving Growth and Change Through the Application of an Integrative Theoretical Approach to Address Multiple Client Difficulties
• Chapter 5: Locating the Locus of Evaluation: The Subtle Processes of Person-Centred Counselling
• Chapter 6: The Use of CBT With Complex Client Issues: Accessing Schemas
• Chapter 7: Walking Back to Happiness: A Couple’s Incongruent Perception of Chronic Illness
• Chapter 8: Treating the Family: A Process Report On Systemic Therapy
• Chapter 9: A Case Study of an Intervention With a Client Suffering from Intrusive Thoughts and Traumatic Grief
• Chapter 10: REBT: The Case of Richard
• Chapter 11: Using CBT to Address Guilt Over Sexual Fantasies: A Process Report
• Chapter 12: Treating Co-Morbidity In an NHS Context: A CBT Approach
• Chapter 13: Historical Truths Versus a Sense of Integrity: Developing a Frame of Mind to Enable Letting Go
• Chapter 14: Depression: A Case Study
• Chapter 15: Working With Children: A Communicative Approach
• Chapter 16: Substance Abuse: Treatment Using Personal Construct Psychology
• Chapter 17: When Things Go the Therapist’s Way: The Case of Sarah
• Chapter 18: Client Case Study: A First Attempt At Psychodynamic Individual Therapy
• Chapter 19: How Not to Write a Client Report: Discussing Common Errors a Trainee Makes
• Chapter 20: Conclusions