Description
Guide for the Written Case Study and Treatment Plan Assignment
The following is an overview of the written case study and treatment plan assignment. The case
study format has been in use going back to the earliest days of the fields of psychology and counseling
and has its origins in medicine. Case studies can be an effective way of communicating clinical
information for the purposes of training, consultation, and supervision. Do not include case notes or
lengthy verbatim quotes from sessions in this assignment. Make every effort to guard client
confidentiality by disguising personally identifiable information (e.g., use a pseudonym or assigned
initials, use age rather than stating date of birth, generally describe the client’s school or employer
rather than naming it specifically, etc.). Ongoing cases are preferred over terminated cases. Do not
submit a case about which you have previously written and do not use the same case as your in-class
Oral Case Presentation this trimester, unless the size of your caseload makes this prohibitive.
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Guide for the Written Case Study and Treatment Plan Assignment
Chad Tynan, LMFT
Department of Psychology, Golden Gate University
PSYCH 394: Practicum in Counseling Psychology
May 6, 2023
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Guide for the Written Case Study and Treatment Plan Assignment
The following is an overview of the written case study and treatment plan assignment. The case
study format has been in use going back to the earliest days of the fields of psychology and counseling
and has its origins in medicine. Case studies can be an effective way of communicating clinical
information for the purposes of training, consultation, and supervision. Do not include case notes or
lengthy verbatim quotes from sessions in this assignment. Make every effort to guard client
confidentiality by disguising personally identifiable information (e.g., use a pseudonym or assigned
initials, use age rather than stating date of birth, generally describe the client’s school or employer
rather than naming it specifically, etc.). Ongoing cases are preferred over terminated cases. Do not
submit a case about which you have previously written and do not use the same case as your in-class
Oral Case Presentation this trimester, unless the size of your caseload makes this prohibitive.
Grade Breakdown
This assignment is worth a total of 100 point and is broken down by headings as follows:
Style, Writing, and Content by Heading
APA Style
Overall Writing and Grammar
Case Context and Method
Case Description
Diagnosis
Case Formulation
Treatment Plan
Course of Treatment
Countertransference
Limitations of Treatment
Legal and Ethical Considerations
Treatment Outcome
Prognosis and Referrals
Total Points Possible:
Points Possible
5
10
5
20
5
15
5
10
5
5
5
5
5
100
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Grading Rubric
Full Points
90% Points
75% Points
50% Points
All of the following:
Any of the following:
Any of the following:
Any of the following:
Free of spelling and
Few and minor spelling or
Multiple minor spelling or
Multiple and significant
grammatical errors;
grammatical errors;
grammatical errors;
spelling and grammatical
includes all relevant
includes all section
missing moderate
errors; missing multiple
headings, subheadings,
headings but missing
content details from
details from guide;
and content details from
minor content details
guide; satisfactory
unsatisfactory application
guide; demonstrates
from guide or missing
application of
of theory/concepts; or
mastery of
subheadings;
theory/concepts;
demonstrates
theory/concepts;
demonstrates working
inaccurate diagnosis but
unsatisfactory clinical
accurate diagnosis; and
knowledge of
correct diagnostic class;
work.
demonstrates excellent
theory/concepts; or
or demonstrates
clinical work.
demonstrates satisfactory
satisfactory clinical work.
clinical work.
25% Points
10% Points
No Points
Any of the following:
Any of the following:
Any of the following:
Difficult to comprehend
Unsatisfactory content
Missing section heading
sentences due to spelling
details from guide or
entirely; missing core
or grammatical errors;
does not use language
content from guide; no
missing substantial
from theory/concepts to
APA Style; no application
details from guide or
case at all.
of theory/concepts to
subheading; does not
case; missing/inaccurate
apply theory/concepts to
diagnosis; or
case effectively; or
demonstrates clinical
demonstrates poor
work that may cause
clinical work.
harm.
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Formatting and Length
Please write using APA Style for Student Papers found in the Publication Manual of the American
Psychological Association, Seventh Edition (2020). Appropriate use of APA Style accounts for 5% (or half
a letter grade) of this assignment. To receive full credit, the case study and treatment plan (including
title page) must not exceed 18 pages in length, double-space the entire paper, 1 in. margins on all sides,
student paper title page, numbered pages, no abstract, no author note, and no running header. The
references section is not required unless another work is specifically cited, quoted, or paraphrased. Visit
https://apastyle.apa.org/ to access the APA Style website where handouts, sample papers, and other
helpful resources are found.
Required Section Headings, Subheadings, and Content
The following sections have been adapted from the guidelines for submitting case reports to the
Asian American Journal of Psychology. Inclusion of all the following section headings and subheadings is
required to receive full credit on the assignment. Note any gaps in data and reason data were not
collected (e.g., brevity of assessment or treatment, client or caretaker declined to provide information,
etc.). Additional headings or subheadings may be used for clarity, organization, or to better fit your style
of writing. APA Style for headings has changed in the current Publication Manual, so be sure to double
check your formatting.
Case Context and Method
Introduce the context or setting in which your work occurs and methods for gathering clinical
data. Describe the treatment setting (e.g., school counseling center, outpatient mental health clinical,
hospital, etc.), service delivery method(s) (e.g., in-person, phone, telehealth, text chat, etc.), and sources
of clinical information (e.g., case notes, audio- or videotaped sessions, patient or therapist self-report
measures, diaries or other reporting forms, information from significant others, clinical records,
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therapist reflections, etc.). Do not report on legally required privacy measures (e.g., HIPAA) and other
customary practices. Rather, describe the precautions taken to prevent disclosure of the client’s identity
in authoring this paper and whether the client consented to student paper reporting.
Case Description
This paper is intended to reflect that your client is an individual who exists is multiple contexts,
has valuable lived experiences, possesses strengths traditionally overlooked by theoretical models and
treatments modalities, and must be viewed through a broader lens than diagnostic labels provide.
Efforts to help and best intentions may harm when there is a failure to honor our clients’ humanity,
dignity, perspectives, and lived experience. The content following this heading and its four subheadings
should be a narrative.
Start this section by introducing the client using a pseudonym or initials, provide demographic
information, and use objective visual, verbal, and non-verbal observations. This may take the form of a
brief mental status exam and include age, appearance and dress, physical description (e.g., height,
weight, hair and eye color), racial identity, gender identity, gender assigned at birth, sexual orientation,
pronouns, marital/relationship status, mood, affect, speech, orientation (to person, place, and date),
hallucinations, delusions, suicidal ideation, insight, judgement, and substance intoxication/withdrawal
symptoms. Describe if this data was collected during a formal assessment or informally during
treatment.
Presenting Problem
Describe the client’s presenting problem as the client understands it, not your explanation or
understanding of the problem. If the client was referred for treatment, describe how and why. Include
the client’s individual or cultural explanation of the problem, stressors, strengths, and supports (i.e., the
client’s description of what helps and hurts, what they may or may not ne ed, and any treatment or
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provider preferences). Note if client is mandated or otherwise required to participate in treatment and
why.
Biopsychosocial History
Include relevant psychosocial history, such as family history and dynamics that directly affect
the condition of the client, adverse childhood events, exposure to trauma, quality of peer relations,
relationship history, education and employment history, developmental delays and disability, and timing
of help-seeking or referral to treatment. Use a broad definition of family, which may include blended
families, chosen family, romantic partners, unmarried partners, roommates, friends, neighbors, and
other community members significant to the client. Report on quality of social relationships, use of
social and cultural supports, engagement with religious communities, spirituality, hobbies, talents,
interests, and other strengths and supports. Include reports of any known relevant medical conditions,
onset of diseases, treatments and outcomes, and prescribed medications and adherence. Include use of
substances, even if the pattern of use and related symptoms do not meet diagnostic criteria for a
disorder. If any of this information is unremarkable or unknown, please indicate.
Diversity, Intersectionality, and Impact
Thoughtfully consider diversity as it applies to the client. Include details of intersecting identities
of race, ethnicity, indigenous heritage, nationality, social class, gender, age, sexual orientation, religion,
disability, language capacity, etc. that may not have been previously stated. Describe how the
intersection of multiple identities impacts the client’s experiences of self, others, family, institutions,
society, and other systems; the client’s sense of agency and safety; the client’s experiences of and/or
beliefs about structural and individual racism, prejudice, and xenophobia; and impact on the client as it
pertains to preferential treatment, oppression, privilege, power, access, opportunities, and other facets
of equity and justice.
Psychological Treatment History
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Include a brief timeline of known prior psychological, counseling, and psychiatric treatments;
types of therapies; titles of previous providers (e.g., MFT, PCC, psychiatrist, social worker, pastoral
counselor, etc.); and treatment outcomes. Indicate if a release of information was obtained to speak
with previous or current practitioners, and rationale for why or why not. List prescribed psychiatric
medications and adherence, if known. If the client has no prior treatment history, then state as much.
Diagnosis
This first portion is only a bullet point list. Use bullet points to list each DSM-5-TR diagnosis
(including appropriate specifiers), substance use disorders, relevant medical conditions, and/or other
conditions that may be a focus of clinical attention (so-called “Z codes”) relevant to this case. Inclusion
of ICD-10 codes (F codes) is optional. List all conditions for which the client meets diagnostic criteria,
even if they are not a focus of treatment. This is not a narrative, just a list. If you are just beginning with
a client or have not finalized a diagnosis, write “(provisional)” as a specifier for the diagnosis.
Unspecified and other specified diagnoses are sometimes more appropriate than a provisional diagnosis.
Do not copy and paste the diagnostic criteria from the DSM-5-TR. Assume the reader has access and can
look up the criteria.
Justification of Diagnosis
This portion is a narrative. Justify the listed diagnoses and other conditions using reported and
observed symptoms and other relevant diagnostic information. Do not restate the entire DSM-5-TR
diagnostic criteria for each disorder. Summarize how the client’s presentation satisfies each criterion for
the disorder. For example, if you have a client who carries the diagnosis of schizophrenia, you could
write: “Criterion A of schizophrenia is met by report of daily delusions and hallucinations for the past 2
years.” If known, include the following details about symptoms: approximate timing of onset ( e.g., days,
weeks, months, or years ago), severity (e.g., mild, moderate, severe), frequency (e.g., daily, weekly,
periodic, episodic, etc.), and description of clinically significant distress (i.e., client’s subjective
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experience) or impairments in areas of life functioning (i.e., how the symptoms interfere with social
functioning, school, work, activities of daily living, etc.).
Diagnoses and conditions that have been excluded or ruled out are important to note. This is an
opportunity to develop skills in differential diagnosis or distinguishing one disorder from another with
similar clinical features. Describe why you chose one diagnosis over another and when diagnostic
criteria were not met for a disorder under consideration. Remember that some disorders can be
unspecified when there is insufficient information to differentiate a diagnosis from those in a diagnostic
class, or when the client presents with clinically significant distress or impairments in functioning but
does not meet full criteria for any of the disorders in a diagnostic class.
Case Formulation and Theoretical Orientation
This is your clinical assessment and formulation of the etiology of the client’s problem(s).
Describe how you make sense of the client’s problem(s), which may differ from the client’s
understanding, but it need not differ. State the specific theory or theories used to formulate or
conceptualize the problems in this case. Describe the problem(s) using the terminology of your stated
theory or theories. Describe what functions symptoms may serve and how they created or maintain the
problem. If you are using a different modality to treat the problem than the one used for case
formulation (i.e., using a psychodynamic theory to conceptualize the problem but using cognitivebehavior therapy to treat it), state the treatment modality and your rationale for doing so. Include why
the treatment modality is appropriate for the client, why it is appropriate for the diagnosis, and any
other factors that determined the modality of treatment (e.g., your own interests, preferences, training,
site or payor requirements, or supervisor instructions).
Treatment Plan and Goals
This section may be a narrative, bullet points, or some combination of the two and should not
exceed two pages in length. Present a summary of the treatment plan and goals, as appropriate to the
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therapeutic modality applied. There are myriad formats for creating and displaying treatment plans and
goals. Your training site may require use of a specific format or may not require a formal written
treatment plan at all, but there should be something guiding the treatment that is informed by your
assessment, diagnosis, case formulation, theory, and your client’s desired outcomes. Be sure to address
relevant risks in the treatment plan, such as suicidal or homicidal ideation/behaviors, severe psychosis,
and substance use that exacerbates the problem. If the treatment plan and goals have been revised over
the course of treatment, summarize the initial treatment plan and goals. Describe revisions to the
treatment plan and goals in the course of treatment section of the paper.
In the absence of an existing treatment plan, the following may be helpful in articulating a plan
for the purposes of this assignment: using the language of your theoretical orientation/treatment
modality, identify problems or symptoms to address in the treatment plan; define goals related to these
problems or symptoms; identify observable and measurable objectives (or outcomes) that will
demonstrate progress toward the stated goals; and list specific interventions designed to support each
objective.
Course of Treatment
First, state the length of time you and the client have been working together, the frequency of
your sessions, the duration of sessions, and note any patterns in absence or engagement.
Chronologically review the course of therapy to date. Start at the beginning of treatment (or the intake,
if this data is available) and describe how it progressed. Subheadings may be useful to organize your
writing into treatment phases. Describe specific therapeutic strategies and interventions you employed,
and the client’s reaction to them. Methods of monitoring or assessment should be appropriate to the
therapy modality applied and may include the use of standardized measures at different time points of
the treatment (intake, during treatment, termination), discussions between the therapist and client
regarding treatment gains, homework and goal-tracking, collateral information, etc. Brief quotes may be
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used to illustrate the therapeutic process at critical junctures. If applicable, this section should also
describe revisions to the initial treatment plan. This section may also present confounding factors or
unanticipated challenges in the therapy. These may include intrapersonal, interpersonal, or external
events. Close with how treatment ended or where it is to date.
Countertransference and Personal Reactions
Even if your theoretical orientation or treatment modality does not incorporate the concept of
countertransference, report on it here. Note if this case brought to mind experiences, thoughts, urges,
reveries, feelings, lapses in attention, or somatic reactions similar to other cases or to your own personal
experiences. Describe the nature (i.e., defensive, reactive, protective, caretaking, disproportionate, etc.)
of the countertransference experiences, how and if these reactions were managed or addressed
(consultation, personal psychotherapy, or supervision), and any resulting enactments. Report any
specific personal, cultural, or professional characteristics that may have impacted (positively or
negatively) your work with the client.
Limitations of Treatment
This is not a section to place blame on yourself (i.e., trainee status, lack of experience, etc.) or
the client (i.e., lack of insight, poor judgement, resistance, etc.) for a treatment outcome. Limitations are
factors outside of the therapy that have a direct impact on the outcome, such as programmatic or
financial constraints on number of sessions, language barriers, job loss, lapse in insurance, relocation,
interruptions due to transportation issues, or school breaks. If you are unable to identify factors limiting
the effectiveness of treatment, describe the factors and conditions supporting treatment.
Legal and Ethical Considerations
Every case has both legal and ethical considerations. That is not to say that every case has legal
and ethical problems or issues that arise, only that the law and professional codes of ethics apply in each
case. Some legal considerations to report on are danger to self or others, mandated child or elder abuse
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and neglect reporting, minor consent for treatment, legal and physical custody, guardianship or
conservatorship, privacy, confidentiality, and privilege. Some ethical considerations to report on are selfharm and safety plans, conflicts of interest, confidentiality, and management of multiple relationships.
Discuss how these concepts applied to and informed your work in this case. Skimming of a counseling
law and ethics textbook table of contents may help jog your memory.
Treatment Outcome
No new details should be reported here that were not included in the course of treatment.
Describe the outcome of the therapy to date as it pertains to the client’s presenting problems and
treatment goals, and any follow-up data available. Describe what treatment plan objectives or goals
were met or remain unmet, and other outcomes (positive or negative) resulting from treatment. If
applicable, discuss any issues with the termination process and reasons for termination (i.e., premature,
treatment completed, referred out, etc.).
Prognosis and Referrals
A prognosis is a prediction or educated guess about the probable course of a disease or disorder
and includes a description about how symptoms may improve, worsen, or remain stable over time.
Ratings of “excellent, good, fair, poor” are most often used to describe a prognosis. Describe what
factors and clinical assumptions you made in reaching this conclusion and what factors may influence
the prognosis. List any referrals you provided to the client and why you felt they were necessary. If no
referrals were provided, please state so.
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