counselling case study examples

Writing a Counselling Case Study

As a counselling student, you may feel daunted when faced with writing your first counselling case study. Most training courses that qualify you as a counsellor or psychotherapist require you to complete case studies.

Before You Start Writing a Case Study

However good your case study, you won’t pass if you don’t meet the criteria set by your awarding body. So before you start writing, always check this, making sure that you have understood what is required.

For example, the ABC Level 4 Diploma in Therapeutic Counselling requires you to write two case studies as part of your external portfolio, to meet the following criteria:

• 4.2 Analyse the application of your own theoretical approach to your work with one client over a minimum of six sessions.
• 4.3 Evaluate the application of your own theoretical approach to your work with this client over a minimum of six sessions.
• 5.1 Analyse the learning gained from a minimum of two supervision sessions in relation to your work with one client.
• 5.2 Evaluate how this learning informed your work with this client over a minimum of two counselling sessions.

If you don’t meet these criteria exactly – for example, if you didn’t choose a client who you’d seen for enough sessions, if you described only one (rather than two) supervision sessions, or if you used the same client for both case studies – then you would get referred.

Check whether any more information is available on what your awarding body is looking for – e.g. ABC publishes regular ‘counselling exam summaries’ on its website; these provide valuable information on where recent students have gone wrong.

Selecting the Client

When you reflect on all the clients you have seen during training, you will no doubt realise that some clients are better suited to specific case studies than others. For example, you might have a client to whom you could easily apply your theoretical approach, and another where you gained real breakthroughs following your learning in supervision. These are good ones to choose.

Opening the Case Study

It’s usual to start your case study with a ‘pen portrait’ of the client – e.g. giving their age, gender and presenting issue. You might also like to describe how they seemed (in terms of both what they said and their body language) as they first entered the counselling room and during contracting.

If your agency uses assessment tools (e.g. CORE-10, WEMWBS, GAD-7, PHQ-9 etc.), you could say what your client scored at the start of therapy.

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Writing a Case Study: 5 Tips

Describing the Client’s Counselling Journey

This is the part of the case study that varies greatly depending on what is required by the awarding body. Two common types of case study look at application of theory, and application of learning from supervision. Other possible types might examine ethics or self-awareness.

Theory-Based Case Studies

If you were doing the ABC Diploma mentioned above, then 4.1 would require you to break down the key concepts of the theoretical approach and examine each part in detail as it relates to practice. For example, in the case of congruence, you would need to explain why and how you used it with the client, and the result of this.

Meanwhile, 4.2 – the second part of this theory-based case study – would require you to assess the value and effectiveness of all the key concepts as you applied them to the same client, substantiating this with specific reasons. For example, you would continue with how effective and important congruence was in terms of the theoretical approach in practice, supporting this with reasoning.

In both, it would be important to structure the case study chronologically – that is, showing the flow of the counselling through at least six sessions rather than using the key concepts as headings.

Supervision-Based Case Studies

When writing supervision-based case studies (as required by ABC in their criteria 5.1 and 5.2, for example), it can be useful to use David Kolb’s learning cycle, which breaks down learning into four elements: concrete experience, reflective observation, abstract conceptualisation and active experimentation.

Rory Lees-Oakes has written a detailed guide on writing supervision case studies – entitled How to Analyse Supervision Case Studies. This is available to members of the Counselling Study Resource (CSR).

Closing Your Case Study

In conclusion, you could explain how the course of sessions ended, giving the client’s closing score (if applicable). You could also reflect on your own learning, and how you might approach things differently in future.

How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

Created by Experts. 100% Science-based.

The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Person-Centered Therapy Case Study: Examples and Analysis

Introduction

Welcome to The Knowledge Nest's in-depth exploration of person-centered therapy case study examples and analysis. We aim to provide you with comprehensive insights into the therapeutic approach, techniques, and outcomes associated with person-centered counseling. Through real-life case scenarios, we demonstrate the effectiveness of this humanistic and client-centered approach in fostering personal growth and facilitating positive change.

Understanding Person-Centered Therapy

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a compassionate and empathetic therapeutic approach developed by the influential psychologist Carl Rogers. This person-centered approach recognizes the profound significance of the therapeutic relationship, placing the individual at the center of the therapeutic process.

Unlike traditional approaches that impose solutions or interpretations on clients, person-centered therapy emphasizes the innate human capacity to move towards growth and self-actualization. By providing a supportive and non-judgmental environment, therapists aim to enhance clients' self-awareness, self-acceptance, and self-discovery. This holistic approach has proven to be particularly effective in addressing a wide range of mental health concerns, empowering individuals to overcome challenges and achieve personal well-being.

Case Study Examples

Case study 1: overcoming social anxiety.

In this case study, we explore how person-centered therapy helped Sarah, a young woman struggling with severe social anxiety, regain her confidence and navigate social interactions. Through the establishment of a strong therapeutic alliance, her therapist cultivated a safe space for Sarah to explore her fears, challenge negative self-perceptions, and develop effective coping strategies. Through the person-centered approach, Sarah experienced significant improvements, enabling her to participate more actively in social situations and regain a sense of belonging.

Case Study 2: Healing from Trauma

John, a military veteran suffering from PTSD, found solace and healing through person-centered therapy. This case study delves into the profound transformation John experienced as he worked collaboratively with his therapist to process unresolved trauma. By providing unconditional positive regard, empathetic listening, and genuine empathy, the therapist created an environment where John felt safe to explore his traumatic experiences. With time, he was able to develop healthier coping mechanisms, embrace self-compassion, and rebuild a sense of purpose.

Case Study 3: Enhancing Self-Esteem

In this case study, we examine Lisa's journey towards building self-esteem and self-worth. Through person-centered therapy, her therapist empowered Lisa to identify and challenge deeply ingrained negative self-beliefs that inhibited her personal growth. By offering non-directive support, active listening, and reflective feedback, the therapist enabled Lisa to develop a more positive self-concept, fostering increased self-esteem, and self-empowerment.

Analysis of Person-Centered Therapy

The therapeutic relationship.

Person-centered therapy places profound importance on the therapeutic relationship as the foundation for positive change. The therapist cultivates an atmosphere of trust, respect, and authenticity, enabling the individual to feel heard and valued. By providing unconditional positive regard, therapists create a non-judgmental space where clients can freely explore their thoughts, emotions, and experiences.

Client-Centered Approach

The client-centered approach encourages individuals to take an active role in their therapeutic journey. The therapist acts as a facilitator, guiding clients towards self-discovery and personal growth. By allowing clients to set the agenda and directing the focus of sessions, the person-centered approach acknowledges the unique needs and perspectives of each individual.

Empowering Self-Awareness and Growth

Person-centered therapy seeks to unlock individuals' innate capacity for self-awareness and personal growth. Through empathic understanding, therapists support clients in gaining insight into their emotions, thoughts, and needs. This heightened self-awareness helps individuals develop healthier coping mechanisms, make meaningful choices, and move towards a more fulfilling life.

Person-centered therapy, as exemplified through the case studies presented, offers a powerful and transformative path towards holistic well-being and personal growth. The Knowledge Nest is committed to providing a platform for sharing knowledge, experiences, and resources related to person-centered counseling. Together, we strive to facilitate positive change, empower individuals, and create a more compassionate and understanding society.

Explore more case studies and resources on person-centered therapy at The Knowledge Nest to discover the profound impact of this therapeutic approach.

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Case Study Research in Counselling and Psychotherapy

• John McLeod - University of Oslo, Norway
• Description

- the role of case studies in the development of theory, practice and policy in counselling and psychotherapy

- strategies for responding to moral and ethical issues in therapy case study research

- practical tools for collecting case data

- 'how-to-do-it' guides for carrying out different types of case study

- team-based case study research for practitioners and students

- questions, issues and challenges that may have been raised for readers through their study.

Concrete examples, points for reflection and discussion, and recommendations for further reading will enable readers to use the book as a basis for carrying out their own case investigation.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

Comprehensive, passionate, right out at the growing edge of the psychotherapy research and even slightly beyond it, this book maps out where case study research has come from, what it looks like today, and what its future will look like.

Robert Elliott, Professor of Counselling, University of Strathclyde

This is an excellent book that has been needed by the counselling and psychotherapy profession for some considerable time. It has been worth the wait. John McLeod writes in a clearly accessible style easy to read and absorb and his comprehensive book both captures existing methods and identifies potential methods ripe for development.

Sue Wheeler, University of Leicester

This is an excellent book, and a very much needed addition to the case study methodology literature. It is very comprehensive and covers all aspects of case study methodology. The text addresses the issue intelligently, but is also an introduction for those engaging in case study research.

Mark Widdowson, Director of Training, CPTI Edinburgh

This book does an outstanding job in pulling together the crucially important literature on case studies in psychotherapy practice and research into a coherent, engaging and scholarly whole.

Daniel Fishman, Editor-in-Chief, Pragmatic Case Studies in Psychotherapy, Graduate School of Applied and Professional Psychology, Rutgers University, Piscataway, NJ, USA

McLeod covers in real depth and high quality how to complete case study research, would definitely recommend.

Always have enjoyed John McLeod's writing style ever since I first started training and this book has not disapointed me. My students have said they also find him easy to read and digest, brilliant.

A good book in preparing students how to conduct case study research in counselling and psychotherapy

Very good book that highlights the focus of counselling and psychotherapy using detailed case studies.

John McLeod writes with his usual high level of insight and accessibility in this fascinating book, which is a must for everyone interested in counselling research. The examples provided give a new way of exploring ideas and concepts. Well written throughout, this is a vital book for anyone in the field - practitioners and students alike.

Essential of considering doing case study research - recommended for those who are not yet sure re the method to use for their research

John McLeod has provided an essential reference for training the new generation of research savvy psychotherapists. This book brings more than just the "what" and "how" - it reveals credibility, rigour and dignity in human ways of researching human process to develop more humane practice and research.

This book adds a useful source for students with a particular interest in case study methodology. In particular Counselling students, who struggle with positivistic approaches, welcome such a clear text that puts their own pratice into an evidence-based context.

This is an excellent addition to support students conducting their own research study as part of their higher education training. It clearly helps them to navigate their way through the research process and the use of case study research for further development of counselling practice.

Preview this book

Sample materials & chapters.

Foreword by Daniel B. Fishman, Ph.D., Rutgers University

For instructors

Select a purchasing option, related products.

This title is also available on SAGE Research Methods , the ultimate digital methods library. If your library doesn’t have access, ask your librarian to start a trial .

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

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.

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. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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A Case Using an Integrative Approach to Relationship Counselling

Author: Jan McIntyre

Mark is 28 and has been married to Sarah for six years. He works for his uncle and they regularly stay back after work to chat. Sarah has threatened to leave him if he does not spend more time with her, but when they are together, they spend most of the time arguing, so he avoids her even more. He loves her, but is finding it hard to put up with her moods. The last few weeks, he has been getting really stressed out and is having trouble sleeping. He’s made a few mistakes at work and his uncle has warned him to pick up his act.

This study deals with the first two of five sessions. The professional counsellor will be using an integrative approach, incorporating Person Centred and Behavioural Therapy techniques in the first session, moving to a Solution Focused approach in the second session. For ease of writing the Professional Counsellor is abbreviated to “C”.

After leaving school at 17, Mark completed a mechanic apprenticeship at a service station owned by his uncle and has worked there ever since. His father died from a heart attack when Mark was six years old and his uncle, who never married, has been a significant influence in his life. He is the youngest of three children, and the only boy in the family. One sister (Anne) is happily married with two children and the other (Erin) is single and works overseas. Mark and his mother have a close relationship, and he was living at home until his marriage.

Some of Mark’s friends are not married and say he was a fool for ‘getting tied down’ so young. Mark used to think that they were just jealous because Sarah is such a ‘knockout’, but lately he has started to wonder if they were right. In the last couple of months, Sarah has been less concerned about her appearance and Mark has commented on this to her. Sarah had been looking for work, but doesn’t seem to do much of anything now.

Three months ago, Sarah found out she can’t have children. According to Mark, she hadn’t spoken about wanting kids so he guessed it wasn’t a big deal to her. When she told him, Mark had joked that at least they wouldn’t have to go into debt to educate them. He thought humour was the best way to go, because he had never been very good at heavy stuff. Sarah had just looked at him and didn’t respond. He asked if she wanted to go out to a movie that night, and she had started to shout at him that he didn’t care about anyone but himself. At that point, he walked out and went to see his brother-in-law, Joe and sister, Anne.

Since then, he and Sarah hardly spoke and when they did it often turned into an argument that ended with Sarah going into the bedroom, slamming the door and crying. Mark usually walked out and drove over to Joe’s place. When Anne tried to talk to Sarah about it, Sarah got angry and told Anne to keep out of it, after all what would she know about it. She had her kids. Joe and Anne had kept their distance since then. Mark talked to his mother, but she said that this was something he and Anne had to work out together. It was she who suggested that Mark come to see C.

Session One

When Mark arrived for the first session, he seemed agitated. C spent some time developing rapport, and eventually Mark seemed to relax a bit. C described the structure of the counselling session, checked if that was ok with Mark, then asked how C could help him.

Mark: “I really wanted Sarah to come; my wife, but she said that I need to sort myself out. I have to tell you, I don’t think counselling is really for men. Women are the ones that like to talk for hours about their problems. I only came here because she insisted and I don’t want her to walk out on me.”

C: “Your marriage is important to you.”

Mark: “Yeah, sure. We’ve had fights before, but they weren’t anything major. And we always made up pretty quickly. But this is different. It seems like whatever I say is wrong, you know? Lately, I haven’t been able to concentrate properly at work and I wake up a lot through the night. I’m feeling really tired and I wish Sarah would get off my case.”

C used encouragers while Mark described what had been happening over the past few months. When he had finished ventilating his immediate concerns, C, moving into Behavioural techniques, summarized and asked Mark to decide what issue he wanted to deal with first. “Mark, you have discussed a number of issues: you are concerned that communication between you and Sarah has been reduced to mostly arguments; you’re unsure how to deal with the fact that Sarah cannot have children; you want to improve your relationship with Sarah; you are worried that Sarah might leave you, and you are feeling very stressed out. What area would you like to work on first?”

Mark: “I just want her to talk to me without arguing. All this is making it really hard for me to concentrate at work, you know.”

C: “Sounds like two goals there, to reduce your stress and to improve communication between Sarah and yourself.”

M: “Yeah, I guess so. If she would just talk to me instead of crying.”

C used open questions and reflections to encourage Mark to look at his feelings. “How do you feel when she goes into the bedroom and starts crying?” Mark: “Well, she’s never been a crier, and I don’t know what to say to her. If I mention not having children, she will probably cry even more.”

C: “So you feel confused about what to do, and anxious that you may upset her even more.”

Mark: “Yes, I just can’t seem to think straight sometimes. Like, I want things to be the way they were, but it’s just getting worse.”

C informed Mark about the use of relaxation techniques to reduce his stress and checked out if he would like to give it a try. “Mark, you appear to be having difficulty coping because you are feeling very stressed. I believe that learning relaxation techniques would decrease the level of stress and help you think more clearly. How does this sound to you?”

Mark: “I’m not into that chanting stuff if that’s what you mean.”

C explained that there are many forms of relaxation and described the deep breathing and muscle tensing method; Mark agreed to do this for 10 minutes twice a day.

As the first session drew to a close, C reviewed the relaxation technique and asked Mark to practise it as often as possible. A second appointment was arranged for the following week.

At the next session, C asked Mark how the relaxation exercise had helped. “I forget to do it some mornings, so I did it for twenty minutes at night instead. I told Sarah what I’m doing and she just leaves me to it. Not sure if it’s making any difference but I’ll keep doing it. It’s nice to have twenty minutes of peace and quiet.” At this point, C moved into a Solution Focused approach.

C congratulated Mark on commencing the relaxation practice, then checked out if it was okay to ask him some different types of questions. Mark agreed and C asked a miracle question. “Imagine that you wake up tomorrow and a miracle has happened. Your problem has been solved. What would other people notice about you that would indicate things are different?”

Mark looked at C, who waited in silence. Eventually Mark responded. “Ok, they would see me and Sarah talking a lot more, without arguing.”

C: “What else would they notice about you?”

Mark: “I would probably be spending more time at home. You know, not staying back so late at work.”

C: “What would they notice that was different about Sarah?”

Mark: “That’s easy. She wouldn’t be crying and yelling all the time.”

C: “So what would she be doing instead?”

Mark: “I guess she would be talking to me, and smiling.”

After spending some time exploring what would be different if the miracle happened, C asked Mark what he had tried in the past to improve communication. Mark revealed that he bought Sarah some flowers and a box of chocolates (his uncle’s suggestion) but it hadn’t really made any difference. C complimented Mark on his efforts and continued with an exception question.

“Can you think of a recent occasion, when you would have expected a quarrel to start and it didn’t?”

Mark furrowed his brow and appeared to be thinking deeply for some time. C waited in silence. Finally, Mark answered. “Actually, about a week ago, I was a bit late home from work and I was expecting another tongue-lashing, but it never came.”

C asked Mark what was different about that night.

Mark: “Well, Sarah was happier.”

C: “How did you know she was happier?”

Mark: “She talked to me, you know, just talked about something she had seen on the telly or something like that.”

C: “And how was that for you, Mark?”

Mark: “Not bad. Actually, it wasn’t too shabby. We did get to chat, and we haven’t done that for ages.”

C: “Can you explain, “Wasn’t too shabby”; I haven’t heard that term before?”

Mark: “Oh, it means it was all good, you know, it was okay.”

C: “So you came home and chatted with Sarah over a cuppa and you found that wasn’t too shabby?” Both smiled

Mark: “I really liked it. I remember thinking I would have come home earlier if I had known it was going to be like that.”

C: “If I was to ask Sarah what was different about that night, what do you think she would say?”

Mark: “Boy, this is getting weird.”

Mark: “Let’s see. She would probably say, “He actually sat and had a cup of coffee with me, instead of just flopping in front of the telly. She’s always griping about that.”

At the appropriate time, C called for a break. “I’d like to take a break and give us both time to consider all the things we’ve talked about. After that, I will give you some feedback.” After the break C summarized what had been discussed and complimented Mark on the work he had put into exploring his problems. He seemed less stressed and had shown that he was committed to improving his relationship with Sarah.

Counselling continued for another three sessions, by which time Mark’s stress had reduced considerably, he was coming home from work earlier and making an effort to talk more to Sarah. The arguments were less frequent and not so heated.

Session Summary

The Person Centred approach allows the client to take the lead and discuss issues as they see them. This encourages the client to talk openly, which was especially useful in this instance since the client showed a reluctance to do so at first.

• The Behavioural technique of goal setting is used to clarify what the client wants to achieve out of the sessions.
• Solution Focused Therapy , this approach acknowledges that the client has the ability to solve his own problem.
• Miracle questions assist the client to examine how they and others would be behaving if the problem were already dealt with. This helps the client to look at their current behaviour and see what they can do to bring about the required change.
• Exploring what the client has tried in the past highlights that the client is committed to solving the problem. Exception questions help the client to see that there are times when the problem does not occur, and that they have contributed to that situation. This shows the client that they have control over the problem.
• Clarifying client’s words, eg. “Not too shabby” shows respect for the client’s language and emphasises that the client is the expert.

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Couple Cases

Below you’ll find case studies of real clients that have attended couple’s counselling at All in the Family Counselling with our professional trained marriage expat counsellor. These cases do not represent all cases seen at our centre but rather are intended to give you insight into what makes for successful outcomes and the time and effort the clients choose to put in to make their relationship change. Each couple’s relationship is unique and has its own history which our therapist will attend to. But we hope you will find it helpful to see what successful clients choose to do and their outcomes.

Case Study 1

Profile : Professional couple married for 6 years but known each other for 10 years. The couple is in their early 30s.

Reason for Counselling : Couple came into counselling because of husband’s excessive use of pornography, a reduced sexual life and overall lower intimacy in the relationship. Wife was prepared to file for divorce if things didn’t improve rapidly. Wife had loss of trust due to pornography use.

Number of Sessions:   Couple had a total of 4 sessions with husband attending to 2 individual sessions. At the client’s initial session everyone agreed to the problem and what a positive marriage would look like for them.  They were taught basic relationship skills and given homework to practice. At their 2 nd  session, which was 10 days later, we reviewed their homework and both individuals had great revelations about themselves, each other and the relationship. They were taught additional relationship skills and given more homework to practice for 14 days.  The 3 rd  session we reviewed homework and refined skills and integrated new relationship concepts into the relationship including negotiating win-win for the relationship and managing perceptions in communication. Final session was 30 days later in which we reviewed their homework, revised some of their skills and gave them a framework to help identify and remedy problems if they were heading back into old relationship habits.

Success Factors:   This is an unusual case for a couple in crises to come to counselling and so dramatically turn their relationship around. The reason the couple experienced such dramatic success was that they had come into counselling early once the issue of intimacy and pornography were discovered. This couple was also highly motived to make counselling work and they energetically completed their homework in between sessions. The couple also had a lot of positive regard for each other and good personal insight into themselves and each other. The husband also attended a couple of individual sessions to work on stress management.

Case Study 2

Profile : Couple married for over 10 years in their mid 30s. Both have a college education and are professionally employed. Couple has no children.

Reason for Counselling : Counselling was initiated by the wife who had found out only 4 days prior to contacting our agency that her husband had an affair and both of them wanted to repair and improve the relationship.

Number of Sessions:   Couple had a total of 6 sessions over 3 months.  The first session was getting agreement that both couples wanted to repair and improve the relationship. Both parties agreed to not introduce punishment into the relationship as a result of the affair. The couples were given some new basic relationship skills and given homework to complete in between session including not discussing the affair.  Session 2 was 10 days later and the focus was on building a unified goal for the relationship. Four goals for the relationship were mutually identified and agreed to. Couples were given more relationship skills and homework to practice. The next 3 sessions were spread out over 2 months and focused on relationship skills that targeted communications, perceptions and internal control all with the couple doing homework in between sessions. The final session the clients evaluated how they did meeting their goals and they felt they got about 70–85% of each of their goals which was satisfactory for them. They felt confident with their new relationship skills. Trust had been restored, forgiveness was given and communication dramatically improved and the couple was established in their new and improved relationship behaviours.

Success Factors:   Couple came in quickly after finding out about the relationship. Both individuals in the relationship agreed to not introduce punishment into the relationship. This couple was focused on the present and building the future relationship.  The incident and issues of the past were only used as guidelines to help us know what worked and did not work. The couple was highly motivated to repair and improve their relationship and would complete their homework and came prepared to fully engage during the counselling sessions.

Case Study 3

Profile : Professional couple married for 7 years. The couple is in their late 30s. Had a history of infertility and infertility treatments that resulted in 2 children in last 3 years prior to treatment.

Reason for Counselling : Couple came into counselling because of dramatically reduced intimacy, increased fighting, difficulty communicating and negative perceptions of each other’s behaviours.

Number of Sessions:   Couple had a total of 12 sessions with each client engaging in 2 individual sessions within 5 months. The first session focused on stabilizing the relationship and providing them with basic relationship skills. The homework started to focus the couple on building positive regard towards each other.  Then next 2 sessions were focused on developing a new relationship base from which to make all decisions-shifting it away from the children as the base and back to the couple.  The next 4 sessions included reviewing the homework the clients were completing in between sessions, the lessons and observations they were learning as well as modifying and enhancing basic communication skills that included perception taking, learning to negotiate a win–win for the relationship and continuing to build positive regard.  The individual sessions were focused on personal issues that were affecting the relationship.  Individual sessions addressed some of the loss and trauma related to infertility treatments and stress and anxiety management.

Complicating & Success Factors:   This couple had a more complex prolonged history of infertility, stress and trauma that went on for a couple of years prior to entering counselling resulting in a more negative view of each other that reduced trust and positive regard for each other. This increased the number of sessions for the couple and individuals session were recommended.

However, the couple still had enough positive regard for each other and was committed to the counselling process because they really valued what they had earlier in their relationship. While the couple experienced some setbacks initially and was slower to implement their new relationship skills than the previous couples, they managed to keep coming to counselling and do most of the work.  As they start the client was successful because they gave counselling enough time to work and practice their new skills and continue to get feedback and guidance while working both on their relationship issues and individual issues. This couple needed more sessions because there were complicating factors and the issues had been developing for a longer period before coming for help.

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Case Examples

I would not exchange or trade the honor and privilege I have had helping individuals, couples and families since 1987. Along this journey, I experienced many situations of success and seeing people grow and share their positive outcomes.

Below you will find a sample of cases where a client has given me permission to share their experience. Identifying information has been changed to protect confidentiality.

Dr. Chen is a good therapist.  He has helped me clarify perceptions that have blocked my growth and development.  I have been able to resolve the feelings that have grown from the misperceptions.  In counseling, I have learned new attitudes and language to help improve my marriage and family relationships.  The barriers I have built up over the years are being removed.  This process takes a long time, but I think it has moved at an appropriate pace.  Other counselors have taken much longer to help me even begin the healing process.  I have made great progress while working with Dr. Chen.

Dear Dr. Chen,

I am writing to express my appreciation for your knowledge and understanding in helping us deal with our teenager’s issues. We were very distraught when we learned about our child’s problems. As with any parent, we were concerned for our child and feared for the worst. We didn’t know what to expect or how to help our child.

Your extensive knowledge and expertise helped us understand what was going on and provided comfort and reassurance. Your expertise and ability to relate to our situation helped us get through a very difficult time.

Thank you for the competence and calm demeanor you displayed as you helped reassure us during this critical time. I firmly believe that others facing similar problems would greatly benefit from your services.

Thanks again, Bruce L.

After suffering with trichotillomania for 15 years, I felt trapped by my constant urges to pull my hair.  3 weeks after seeking professional help from you, I was able to greatly reduce the amount I pulled my hair.  By using the tools I learned in therapy, I can go several days at a time without pulling and am continually improving.

Thank you! Kelsey

Alcoholic Alan

Not long ago a client (Alan) came in seeking help for drug and alcohol abuse. He was in his mid 30’s and had been using marijuana, cocaine and methamphetamine since his late teenage years. He started drinking alcohol before he was a teenager.

Alan finished high school and began working in retail. He changed jobs or was fired every couple years but was able to work his way up into a manager position. He was married and had three children. His drinking had a negative impact on his family and occasionally he yelled at his wife and kids. Often he spent time by himself at home watching T.V. or surfing on the Internet.

He wasn’t very satisfied at work and occasionally got into arguments with his assistant manager.  During therapy, it became evident that Alan used drugs and alcohol to cover up his feelings of anger, frustration and at times low self-esteem.

He was able to learn new coping skills and reduce his use of drugs and alcohol. His marriage improved and he enjoyed his kids more. Even his relationship with his assistant manager improved.

Co-dependent Cathy

Cathy had been married for 14 years to her high school sweetheart. Things started out good but as their family grew to four children the first five years, their marital relationship gradually deteriorated. Her husband, a sales manager traveled almost every week. When he was home, he tended to ignore her and the kids.

Cathy would occupy herself with housework, church duties and helping neighbors and other relatives. Most people thought Cathy had a good marriage, but inside she felt empty and trapped.

Feelings of frustration and anger would occasionally rise to the surface, but most of the time she just kept it all inside.

When Cathy started therapy, she had just discovered her husband had an addiction to pornography. She was surprised, hurt, angry and didn’t know whether she wanted to stay in the marriage or leave. She was concerned about the kids.

The therapy focused on a pattern of behavior called co-dependency. Cathy discovered that her husband was in many ways like her father, who was an alcoholic. She tried to control her family growing up and now she was trying to control her husband.

Gradually Cathy developed a healthy mental separation from her husband and as she began to get healthy, her husband admitted he had a problem with pornography and decided to get help himself.

Anxious Ann

Ann was in her late 20’s and had been working in a secretarial position since graduating from high school. She was nervous and anxious most of the time. She rarely dated but desperately wanted to get married.

However, Ann was afraid to socialize and had few friends. Most evenings she would read a book at home or talk on the phone to her parents or other relatives.

By the time Ann came to therapy, she had begun to have panic attacks and at times she thought she might die. Therapy began by exploring why Ann was not dating. It was discovered that she had been sexually abused by a baby sitter when she was 7 years old. This abuse continued over a two year period. She had never told her parents. Later she was also sexually abused by an uncle.

Ann had strong feelings of anger toward men but also wanted to develop a relationship with a man and eventually get married. Her feelings of ambivalence had developed into anxiety which lead her to isolate and avoid men.

During therapy Ann was able to work through the trauma of the two different periods of sexual abuse. Her anxiety disappeared and then therapy focused on helping her develop appropriate social skills. Ann began dating and recently became engaged.

Depressed Donna

Donna was in her mid 40’s, a typical mother of 4 children, married for over 16 years and active in the community and church.}

She had her first depression with the birth of her first child, and her family doctor prescribed an anti-depressant.

Her husband was supportive and made a decent income, yet money always seemed tight. It was a challenge taking each of the four children to music lessons, dance, football practice and the like, not to mention all the church activities.

Donna never felt like there was any time for herself. In fact, if she did take time to do something she enjoyed, she felt guilty.

She tried to talk to her church leader once, but that didn’t seem to help. She knew there were other women who were depressed and taking medication, but she still felt like no one understood what she was going through.

When she finally came to therapy, she felt hopeless but wanted to change her life. In therapy, she learned to develop some positive thinking skills, not just think happy thoughts, but really challenge some of her long held beliefs that kept her from finding the peace and happiness she knew she had always sought.

She began to enjoy life more and her husband even commented how much happier she seemed. The best compliment was from one of her children who said “mommy, you don’t seem like you’re mad at me anymore”. Donna almost cried. The mixture of joy and sadness she had; joy that she could connect better to her husband and children, and sadness that she hadn’t sought help sooner.

Career Confusion

Tom was in his late 40’s and ready for a new challenge in his life. He had worked in the computer industry for over 20 years and was recently let go from one of the major computer companies.

He first got into the computer industry because it was exciting and new developments were happening all the time. But over the years he became upset by the lack of loyalty that large companies showed their employees.

This was the third time he was a “victim” of a downsizing and he was ready to bail out of computers. But he didn’t have a clue what to do.

When Tom came to career counseling, the first question he asked was “What else am I good at?” He took a battery of assessments and found that he had natural abilities in the science and technology areas. The more he explored, the more interested he became in fixing scientific devices. He enrolled in a course designed to help technicians fix medical devices.

During this course he met another entrepreneur and together they developed a business plan. Tom had found a new challenge and was ready to move forward.

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Counselling Case Study: Working with Grief

Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of each stage will be different for each individual.

It is therefore understandable that an eclectic counselling approach to grief can be beneficial in allowing for the flexibility needed to work with individuals through various stages of the grief process. The following case study is a practical application of a variety of counselling approaches to one client and her experience of grief.

The client’s name is Joan. Joan sought counselling to deal with the unexpected loss of her daughter in a car accident. She received counselling about 2 weeks after her daughter’s death and continued with the counselling process over a period of 8 months.

The key features of Joan’s grief were her feelings of guilt and despair. In these areas, the counsellor worked mainly from a Person-Centered approach (PCT). The counsellor also utilised some techniques from Solution-Focussed Therapy (SFT) and Cognitive-Behaviour Therapy (CBT). A brief analysis of the case study and application of the various techniques are provided below.

Case Information

Joan is a semi-retired accountant, maintaining contract work with a few long-term clients to support herself in retirement. Joan is a divorcee, who lives on her own, in her family home. She is a mother of 2 children, Kirsten and Mathew, aged in their mid 20s. Joan has a supportive network of family and friends, including her sister, father, children, and friends from her gardening club.

Joan’s relatively steady life was overturned with the sudden death of her daughter, Kirsten. Kirsten was 24 when she died from head injuries caused during a car accident. She was admitted to hospital in a coma. Joan spent several anxious days with Kirsten, before she passed away.

In the days that followed, Joan arranged her daughter’s funeral and affairs and deferred her work commitments. Joan described this as a whirlwind period, where she operated in a mechanical way. She was completely absorbed in the organisation of Kirsten’s funeral and pushed aside her feelings of grief. Joan said that she found some security in the numbness that filled her during that time.

After a couple of weeks, however, Joan became concerned that she was not coping as she couldn’t move on from these feelings. People had commented that she should try to carry on as usual, however her numbness persisted and she couldn’t motivate herself to “carry on” as if nothing had happened.

Joan thought that there must have been something wrong with her and it was this fear that led her to counselling some weeks after her daughter’s funeral.

For ease of writing, the professional counsellor in this case will be referred to as “C”.

The Initial Stages

(Numbness) In the first session, Joan appeared somewhat vague and tired. She seemed focussed on describing the details of the funeral, the family members who attended and her concern about her daughter not having a will. “C” observed that Joan’s behaviour reflected a need to be in control of the situation and was a useful coping strategy for Joan at this time. “C” used PCT to build an empathetic understanding of Joan’s experience. She did not attempt to move Joan towards experiencing her grief, but trusted that Joan would reach this stage in her own time.

Joan began discussing the rapid way in which the whole event had occurred and the numbness that she was feeling. “C” used paraphrases and encouragers to assist Joan to express herself. “Everything has happened so quickly that you haven’t had time to absorb it all, is that right Joan?” “Yes”, Joan replied, “I’ve hardly had time to miss my little girl.” “You miss her,” responded “C”.

With this encourager, Joan began to cry and express her grief. Joan cried for some time whilst “C” sat with her in silence. At one point Joan apologised for her crying. “C” responded “It seems that you have a lot to cry about Joan. It shows me how much you loved your daughter.”

In the first session, Person-Centered therapy and Active Listening techniques enabled “C” to be guided by Joan’s readiness to express her feelings. The encouragers and reflection of feeling used, demonstrated to Joan that “C” understood her and allowed Joan to experience her feelings of grief, rather than to keep them at arms length.

Whilst “C” could have indicated to Joan that she was avoiding her grief, “C” instead trusted in Joan’s ability to express her grief in her own time. If Joan had not expressed her grief in this session, “C” would not have pressed the issue, although she may have encouraged Joan to have a further session within a few days.

(Grief and Despair) The following sessions were characterised by further experiences of grief and despair. Joan had found that her grief was no longer avoidable and her days were mostly filled with mourning. Joan abandoned her daily routines such as grooming, making meals and other basic self-care practices.

Joan’s disheveled appearance at the counselling sessions were concerning. At this point, “C” became more directive and suggested that Joan might have someone live-in with her for a while. Whilst “C” was encouraged by Joan’s regular adherence to the counselling sessions, she felt that Joan may need some extra support at home.

Joan contacted her sister Kerrie, who was available to stay with her for a month. Kerrie proved to be good support for Joan and provided her with gentle, yet insistent encouragement to face the everyday challenges.

Over several weeks of counselling, Joan had moved further into stages of despair and guilt. She described her life as being swallowed by a black hole and felt that she would never get over her daughter’s death. She felt that every day dragged by with no release from the pain. She had difficulty getting out of her bed in the morning and was constantly tired from lack of solid sleep.

“C” continued to employ PCT to allow Joan to explore and express her feelings and thoughts about her daughter’s death. Joan focussed heavily on her pain and seemed to stay with these feelings for a long time. “C” observed that Joan’s thoughts did not seem to be focused; she quickly moved from one topic to the next. “C” used summarising skills to help Joan highlight the key recurring issues from her thoughts.

“C” continued to trust that Joan would move through her feelings of grief in her own time. “C” did however experience some frustration with Joan’s continual despair. “C” sought the counsel of a colleague, who advised her to maintain her faith in Joan’s ability to grow and heal and reminded “C” of how the resolution of grief can often be a long-term process. The colleague also suggested some role-play techniques that “C” could use to work on Joan’s experience of her feelings.

(Guilt) Guilty feelings about her inability to prevent her daughter’s death were also of concern for Joan. “C” avoided telling Joan that she was not responsible for Kirsten’s car accident, and encouraged Joan to explore her guilt. In many instances grieving people feel guilt in relation to their loss. Often they will be told that they are not at fault, by well meaning people. The concern for counsellors is that grieving people are feeling guilty and will benefit more from expressing their guilt.

Dismissing guilty feelings won’t stop the grieving person from feeling blame and may lead to the increase of these feelings. “C” realised that Joan’s guilt was a means of expressing how fervently she wished to have her daughter with her still. “C” invited Joan to express her sorrow and guilt to Kirsten in a role play activity.

Afterwards, “C” encouraged Joan to debrief and talk about the effect of the activity. Joan was able to acknowledge the depth of her love and concern for Kirsten. “C” supported Joan by offering encouraging feedback. “C” was particularly taken with the extent of love and devotion that Joan displayed towards her daughter.

Joan left the session a little lighter for the experience. She said that she had been able to release some of her guilt and that she felt her despair ease a little. After two months of counselling, both Joan and “C” recognised this as a small breakthrough of acceptance.

Middle Stages

Joan’s grief and despair continued into the middle phase of the counselling sessions. Her emotions came in waves, rather than the constant fog of despair that had characterised her earlier sessions. “C” was continuing to utilise PCT with Joan to explore her issues. Joan expressed a readiness to establish goals during this stage. “C” implemented some CBT techniques for this purpose.

(Feelings of Panic) Kerrie had been encouraging Joan to take on small, everyday tasks such as walking to the shops, or posting the mail, in order to get out of the house for a while. Joan said she had done these tasks reluctantly as she was concerned about trying to “put on a brave face” in public.

Joan related a particular incident where she was at the local shop. She explained that when picking items from the shelves, she had selected her daughter’s favourite brand of biscuits. Feelings of panic had come over her as she realised that she no longer needed to buy the item, but she couldn’t bring herself to return the item to the shelf. In this state, she left all her purchases in the shop and walked straight home.

This incident had increased Joan’s anxiety about her ability to cope and accept her daughter’s death. In the session, “C” validated Joan’s experiences as being normal and a legitimate part of her grieving. As a part of the CBT process, “C” clarified and identified the causes and effects of Joan’s feelings of panic. These were as follows:

A realisation that her daughter was absent in her everyday life A rejection of awareness that her daughter was absent in her everyday life Conflicting emotions about acceptance of daughter’s absence

• Causing anxiety
• Causing a belief that she will never be able to accept her daughter’s loss
• Causing a fear of losing control in public places

“C” and Joan discussed the nature of the anxious feelings, and Joan’s associated beliefs and fears. Together they devised a number of goals, including (1) the development of new beliefs, (2) relaxation and (3) taking it one step at a time – otherwise referred to as a graded-task assignment.

Joan’s new beliefs included:

• It is normal to want my daughter back
• I am normal to grieve for and miss my daughter
• It doesn’t matter if I cry in public
• Time will help me to heal

She kept notes in a personal journal about when she used these new beliefs. The journal writing was also a process that allowed her to identify other problematic beliefs and thoughts. Once identified, she developed more appropriate and accepting beliefs.

In preparation of taking it one step at a time, Joan and “C” devised some relaxation techniques for Joan to use when she felt a sudden onset of panicky or anxious emotions. Joan had used imagery before and found that an effective method of relaxation. Joan was to imagine a warm, white light surrounding her whenever she felt even slightly anxious. They also devised some imagery to help Joan continue to experience the overwhelming nature of her grief.

Joan often referred to her feelings as a fog, and so “C” encouraged her to imagine sitting in a fog, which was black, thick and impenetrable. Little by little, she suggested that Joan should try to make the fog thin out with her mind. (It is important to note that this imagery was to be used at times when Joan felt bogged down in despair, but not during her anxious moments).

Joan was to record her practice of her relaxing imagery (white light) and to note her responses to the technique. She also recorded the times she used her despairing imagery (black fog) and the extent to which she was able to thin the fog with her mind. The purpose of the exercise was to increase her relaxation and to give her an image of her despair and a means to control it as time went on.

The ‘one step at a time’ goal consisted of Joan taking small steps towards running errands and taking on more of her everyday responsibilities. Her tasks involved the following:

• Plan meals for week
• Write a grocery list
• Go shopping with Kerrie.

Using her relaxation imagery, Joan completed the following graded tasks:

• Imagine walking around the shops
• Drive with Kerrie to the shop and stay in the car
• Walk with Kerrie to the shop door
• Walk with Kerrie around the shop for 10 minutes approximately
• Start to purchase a small number of items
• Complete an entire grocery shopping task

Each week, Joan completed a harder task. It took her only 4 weeks to complete a full shopping trip, although she experienced several occasions of feeling overwhelmed. Each time this occurred she gripped the shopping trolley and imagined the white light. Kerrie encouraged her to breathe deeply and relax. A couple of times, they left the shop (abandoned the trolley) when Joan felt she could not cope. They came back the following day to complete the shopping.

The important thing for Joan was to accept the times when she could not cope. Kerrie proved to be a supportive role model for Joan, helping her to accept her reduced ability to cope by offering encouraging comments and faith that Joan would heal.

Joan applied the graded-task technique to other areas of her life. “C” observed Joan’s increasing attention to self-care and other routines of everyday living.

Final Stages

(Acceptance) Joan’s increasing acceptance of the loss of Kirsten became more obvious with the passing of time. By dealing thoroughly with her despair and grief, she naturally moved on with her life and mourned less and less. After six months, the rewards for both “C” and Joan were evident in her long term improvement and growth.

Joan’s ability to develop goals for herself was greatly improved, as was her motivation. Joan was living independently again and without Kerrie around, she took on more responsibility and began to make plans for her life without Kirsten. Joan’s plans included a number of support mechanisms, as well as long-term goals for herself.

Joan had taken to visiting her daughter’s grave on a monthly basis. During her intense despair, she had been unwilling to venture to the cemetary. Due to her increasing acceptance, she was more inclined to visit and found the visits to be a sad, yet calming experience. The visits allowed her the opportunity to tell Kirsten the things she had left unsaid, and to update her daughter about her life, as she would have when Kirsten was alive. Joan found the visits kept Kirsten’s spirit and memory alive within her.

In these stages, “C” continued using PCT, and incorporated SFT to assist Joan to define her goals. “C” complemented Joan on her inventive ways of honoring her daughter’s memory. “C” was encouraged to see that Joan was actively seeking personal ways to express her grief.

Together, they worked to build Joan’s miracle picture. Joan expressed an interest to honor Kirsten’s life, by writing a book. Joan wanted to combine her own and Kirsten’s journals to recount the significance of her life and death. The process would also be a means to resolve her grief and offer a parting gift to her daughter.

Joan’s miracle picture included redefining her life goals to determine what was important for her. Kirsten’s death, whilst painful, had also brought growth and changes with it, and Joan was increasingly inclined to shed parts of her life that no longer held meaning for her. She threw out material things such as old furniture, files and boxes of junk and mentally discarded the maintenance of acquaintances that she no longer felt obliged to remain in contact with.

She renewed her bonds with close friends and family. Kirsten’s death allowed her family to grow closer to one another. Joan was buoyed by the love and support of these few, special people during her long months of despair.

Joan accepted that she would never completely ‘get over’ Kirsten’s death and that that was okay. Counselling assisted her to realise that her daughter would remain a part of her forever. She made a pledge to herself that she would continue to learn ways to live with Kirsten’s absence. Her journal writings and the possibility of publishing a book for Kirsten, would provide her with some therapeutic means of coping and expressing her grief. Joan would also draw from the support of her family and friends in times of need, particularly around the times of Kirsten’s birthday and the anniversary of her death.

End of Session

The case study has illustrated some of the stages that clients may experience due to the loss of a loved one. It has also attempted to demonstrate the way in which PCT lent itself to the complex and individual experience of Joan. The key issue from the PCT perspective was “C’s” respect for Joan to grieve and grow to acceptance in her own way and time.

CBT was applied to changing Joan’s negative thoughts about her ability to cope with her daughter’s loss and the fear of losing control of her emotions in public places. The imagery was a technique that Joan had prior experience with and was therefore ideal for her. Another client, may prefer other relaxation methods. It is important to identify strategies that the client is comfortable with.

Graded task assignments, journal writing, role plays, homework and other practical strategies such as developing support networks are also invaluable CBT techniques. Timing is important when introducing strategies, and the client should not be pushed into solutions before they are ready to accept them. Wherever possible, the counsellor should consult with the client about their ideas for, and their suitability to, particular techniques.

Once the client is ready to focus on solutions to their problems, SFT can be an invaluable tool for identifying the client’s goals through development of the miracle picture. The use of SFT has been briefly presented in the case of Joan, to illustrate its effectiveness in drawing out the plans and goals that Joan aspired to.

Author: Jane Barry

Related Case Studies: A Case of Grief and Loss ,  A Person Centred Approach to Grief and Loss , A Case of Acceptance and Letting Go

• March 15, 2007
• No Comments
• Case Study , CBT , Person-centred , Solution-focused
• Case Studies , Loss & Grief

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