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How to write a case study

I. Case History
1. 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.

2. 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.

3. Your Diagnosis

Provide your diagnosis and give the appropriate DSM-IV code. Explain how you reached your diagnosis, how the clients symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.
II. Intervention
The second section of your paper will focus on the intervention used to help the client. Your instructor may require you to choose from a particular theoretical approach, or may ask you to summarize two or more possible treatment approaches.

1. 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.

2. Cognitive-Behavioral Approach

Explain how a cognitive-behavioral therapist would approach treatment. Offer background information on this therapeutic approach 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.

3. Humanistic Approach

Describe a humanistic approach that could be used to treat your client. 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.

Tips:
• Do not refer to the subject of your case study as “the client.” Instead, use his or her name.
• Remember to use APA format when citing references.
• Read examples of case studies to gain and idea about the style and format. The following case studies can provide insight on how to write up a case history: Case Studies