MC08 Assessment and Case Conceptualisation
MC08 Assessment and Case Conceptualisation
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CASE STUDY REPORT GUIDELINES
Assessment Task 1
These guidelines should be used as a follow up to the explanations on writing the case
study report given to you on HELP and the assessment requirements listed in your
study guide. The aim of these guidelines is to assist you in developing a framework
within which to summarise various types of clinical information, present assessment
data in a concise manner, and build a client profile based on syntheses of all
assessment results. You should present information in past tense and avoid making
direct references to yourself (the exception for this is section VIII SELFREFLECTION
ON ASSESSMENT of the report). Remember that you are writing this
report for the benefit of another clinician who will be using it to make therapy decisions
about the client you have assessed.
The case study report should begin with a title (brief heading) which states the type of
assessment conducted and the addresses the issue of confidentiality. One example of
such a tile is:
“CONFIDENTIAL REPORT OF COUNSELLING ASSESSMENT”
You will be required to present your assessment procedures and results under the
following six headings:
I REASON FOR PRESENTATION
The purpose of this section is to introduce the client (use a pseudonym, e.g., Mr/Ms
Client), list key demographic information (e.g., age, and gender client identifies with)
and to present the main reason for the client seeking services/assessment. You
might also present key observations of the client in session. Please end this paragraph
by reporting the subjective units of distress (SUDS) rating that the client reported –
e.g., ‘Mr Client reported a subjective units of distress rating of 40 (0 = ‘Totally Relaxed;
100 = ‘highest distress ever felt’), indicating that the presenting issue is associated with
mild levels of distress’).
II RELEVANT BACKGROUND
The purpose of this section is to provide relevant factual details which assist in
describing your client. Examples of such details include relationship types and
employment or study status. Consideration should also be made for any historical or
background information which helps to contextualise the reason for presentation (or
presentation issues). Please ensure that this background information directly relates
to the presenting issue.
III ASSESSMENT PROCEDURES
The purpose of this section is to provide the methodology used in assessing the client
and collecting the relevant data which will be outlined in the report. Introduce each of
the assessments used by stating what each assessment measures and cite the
reference for each measure. You need to communicate how you selected and
administrated assessments to demonstrate that your evaluation is a professional
integration of information from a variety of sources. In other words, you need to provide
a rationale for the use of each assessment. Integrate research literature here to
support your justification/rationale. Be sure to also note who gave the tests and how
long it took. These issues are important if you ever need to report officially (for example
if your assessments are being reported in court).
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IV ASSESSMENT RESULTS
The purpose of this section is to present the results of the assessments undertaken by
the client. Each assessment is given a heading and data from the four assessments
should be summarised separately.
1) Interview Results: This is a clinician-constructed (you are the clinician here) protocol
used to gather relevant information related to the presenting issue, along with relevant
background information. The qualitative information obtained from the semi-structured
interview can be summarised in relation to domain of performance (e.g., emotional,
cognitive, interpersonal, systemic, behavioural etc.). Consider the domain(s) the
client’s presenting issues impact upon. It is important that you demonstrate the ability
to discriminate between different types of information. Avoid repeating any information
presented above in the ‘reason for presentation’ and ‘background’ paragraphs. Your
capacity to develop a semi-structured interview with clear prompt and follow up
questions will be important in gathering relevant information.
2) DASS-42 Results: The DASS is a standardised self-report inventory which is
formally scored. You will need to present the total scores for each subscale and state
what these scores suggest about the client’s current functioning (i.e., interpret the
scores). You will also need to present a table showing the highest scoring items and
briefly comment in-text about what these scores suggest about the client’s current
functioning.
3) Mental Status Exam (MSE): This is a non-standardised observational assessment
which measures mental state/status at a point in time based on key indicators. You
need to address all major elements of the MSE in either narrative or table form. You
should ensure that all observations are backed up with evidence from the client
interview itself. Finally, you should comment both on any particular outcomes that are
indicative of potential issues in mental status function with support from the literature,
as well as what the overall MSE indicates about the client’s mental state.
You are not required to ask any specific questions to test memory, etc., you may purely
rely on your observations of the client’s appearance, demeanour, cooperation, mood,
etc. which you observe during the session as a whole.
Please note: Your client may not demonstrate any particularly abnormal mental status
indicators so you may only need to report the observations themselves.
4) One student selected assessment/ self-monitoring tool or one clinician-constructed
tool: This assessment is clinician-selected (you are the clinician here). This
assessment should provide relevant information which relates to: the presenting issue,
or gaps identified in the assessment data. The reporting of the results will depend on
the type of assessment chosen. Ensure that you include both macro and micro analysis
of the results, as indicated above in the DASS-42 and MSE.
Please note: please see resources on HELP (resources to assist in selecting a fourth
assessment) to help with getting you started. Ensure that the assessment that you
use is brief and free to use. Please do not assess your volunteer clients for
diagnoses (e.g., postnatal depression, PTSD) or for severe symptoms such as
trauma symptoms, alcohol/substance dependence or abuse etc.
V CONCLUSIONS
Data obtained from different assessment procedures are minimally effective to the
testing process if they are only interpreted separately. It is important to review all
results together in order to construct a detailed assessment profile which tells a clear
story about client functioning. You will need to draw together the major trends/patterns
obtained from all assessment procedures, highlight areas in which there was
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consistency between various data sources, and identify any areas of inconsistency.
Your aim is to write a coherent summary that helps in drawing valid conclusions about
client performance.
VI RECOMENDATIONS
The purpose of this section is to provide an end point or conclusion to the report by
providing future directions. In this instance recommendations could refer to either the
implementation of further assessments or recommendations for the next phases of
therapy. Please note that for this task you are not required to discuss treatment or
intervention options as it is unlikely you will have enough information to make such
recommendations.
VII SELF-REFLECTION ON ASSESSMENT
The purpose of this section is to provide you with the opportunity to review the
assessment process you applied, your client’s reactions to this process and the roles
and responsibilities you undertook to ensure that you conducted client-centred and
valid testing. Ensure that you reflect on the presence of any professional or ethical
issues that arose. Assessment occurs within the context of an interaction between
client and therapist and demands that the latter adopt particular behaviours that might
feel unnatural. In completing this section of the report, include a discussion of whether
you might include formal assessment in your day-to-day practice and the reasons for
your response. This is the only section of the report that you can write in first person.
VIII REFERENCE LIST
The reference list should be presented in APA 7 style format.
IX APPENDICES
The appendices should contain all de-identified copies of:
the signed student statement form,
the client confidentiality form (please ensure this is de-identified after
the client writes their name and signs it),
the SUDS rating form completed by the client.,
the questions you asked during the interview,
your notes on client interview responses,
the completed DASS-42 test form,
the completed MSE form,
the completed fourth assessment chosen by you,
and any other supplementary information.
*PLEASE NOTE: Penalties will be applied for submitting appendices and/or reports
with the client’s name visible to the markers. Please ensure that you have de-identified
the client’s name and signature prior to submission (e.g., putting a black line through
the client’s name and signature, so that it is no longer identifiable) for all documents
submitted.
