Case Presentation Format

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Purpose

The clinical case presentation provides trainees an opportunity to practice professional presentation of their clinical work and to receive consultation from their peers along with supervision from the facilitator. It also provides a setting for practice of proto-supervisory skills and for learning about treatment approaches, therapeutic dilemmas, and clinical issues with cases that are not their own. Examples of topics within the context of the case presentation include:

  • Diagnostic Issues
  • Issues of therapeutic frame and boundaries
  • “Fit” between client and treatment approach
  • Therapeutic crisis or impasses
  • Transference and counter transference illustrations and dilemmas
  • Culture-specific clinical issues and treatment modifications
  • Stage of treatment (e.g., termination) issues
  • Case Write-up

 

A week prior to the scheduled presentation, a detailed case write-up (without identifying information) is distributed to all group members. It covers the following:

  • Reason for referral and presenting problem
  • Description of the client (physical, behavioral & social)
  • Brief pertinent life history
  • History of presenting problem and past treatment history
  • DSM-IV Diagnosis on five axis (including secondary diagnoses and rule-outs)
  • Clinical Case Formulation (from any chosen theoretical orientation)
  • Cultural Formulation (using the DSM-IV Guidelines for Cultural Formation)
  • Brief treatment summary and course of treatment
  • Observations on transference/counter transference dynamics in the case
  • Clinical concerns or issues the presenting therapist would like to address

Process Notes

 

Typed process notes of at least one recent psychotherapy hour (as close to verbatim as possible) are distributed to all participants on the day of the presentation. The notes are presented to the group and discussed (in the light of the case data, clinical and cultural formulations, and the issues the presenter wishes to address.)

Presentation

 

Presentations start with questions from the group about what needs to be clarified about the write-up. Then the presenter takes about 10 minutes to present the case and any additional relevant information since the write-up was completed. The purpose here is to help the group better understand what it is like for the therapist to work with this particular client, rather than merely to go over the written text. The group then asks questions/makes comments that aim to add to the formulation. Next, the therapist presents process notes from a recent session. This is followed by a group discussion that focuses mainly on the presenter’s stated concerns. In addition, the Director of Training may ask the conference to focus on a particular clinical or cultural issue relevant to the case.

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