case presentation case conceptualization (cp cc) assignment

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).

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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.

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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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COUC 667 Clinical Diagnosis and Treatment Planning

• Course Description

For information regarding prerequisites for this course, please refer to the  Academic Course Catalog .

Course Guide

View this course’s outcomes, policies, schedule, and more.*

*The information contained in our Course Guides is provided as a sample. Specific course curriculum and requirements for each course are provided by individual instructors each semester. Students should not use Course Guides to find and complete assignments, class prerequisites, or order books.

The Department of Counselor Education and Family Studies is committed to preparing students who can adequately meet the demands of a world that is becoming more and more impaired by sin, dysfunction, and pathology. We desire students who can interview, evaluate, and treat clients professionally, effectively, and ethically without violating their biblical worldview and in a way that integrates that worldview into their work. The intent of this course is to prepare students for the pragmatics of their clinical work in practicum and internship environments. Christian counselors should be competent in all areas of clinical work regardless of the setting in which they work. Being able to conduct an appropriate, professional, and clinically sound interview is the basis of all counseling. Based upon the data obtained in the interview counselors must be able accurately diagnose, conceptualize, and plan a course of treatment for clients, essential skills for all counselors.

Method of Instruction: This 8 week course is delivered in a digital asynchronous format, with  Canvas® as the primary instructional delivery method. Students complete one module per week over the duration of the course. 

Course Assignment

Textbook readings and lecture presentations/notes.

The student will complete required reading and viewing of video presentations in the appropriate module according to the Course Schedule.

Course Requirements Checklist

After reading the Course Syllabus and Student Expectations , the student will complete the related checklist found in the Course Overview. 

Advising Acknowledgement Quiz

The student will review the program handbook and licensure information by following the link within the quiz information. Once reviewed, the student will need to complete the Advising Guide Acknowledgment Quiz.

Discussions (4)

Discussions are collaborative learning experiences. Therefore, the student will complete 4 Discussions in this course. The student will post one thread of at least 300 words. The student must then post 2 replies of at least 150 words. For each thread, the student must support his/her assertions with at least 1 scholarly citation in APA format (in-text citations and references). Any source cited must have been published within the last five years unless it is deemed a seminal work in the field. Acceptable sources include textbooks, peer-reviewed journal articles, government websites, biblical sources (Bible, Bible dictionary, commentary, theological textbooks, etc). (CLOs: A, B, C, D, E, G)

During the clinical interview role-play (CIR) assignment, the student will take on 3 roles: counselor, client, and supervisor using Microsoft Teams video recording. As a counselor, the student will practice the essential counseling skills (e.g., open-ended questions, empathy, reflect emotions, probing) to collect information necessary for a diagnosis. As a client, the student will role play a case study given by the instructor. As a supervisor, the student will observe the counselor using his/her clinical interviewing skills and provide oral feedback. (CLOs: A, B)

The Case Presentation has 4 assignments associated with it. The first 3 are formative, a place to practice, clinicals skills, e.g., assessment, diagnosis, case conceptualization, and treatment planning. The 1st formative assignment is the Case Presentation Assessment & Diagnosis (C-PAD) assignment. For this assignment, the student will use the data collected from his/her clinical interview in previous weeks. The student will write up the first part of the case presentation – assessment summary and a diagnosis. This assignment is 4 to 7 pages in length in APA format, which includes a cover page, headings, subheadings, intext citations, and a reference section. (CLOs: B, C, D)

The Case Presentation has 4 assignments associated with it. The first 3 are formative, a place to practice clinicals skills, e.g., assessment, diagnosis, case conceptualization, and treatment planning.

The 2nd formative assignment is the Case Presentation Case Conceptualization (CP-CC) For this assignment, the student will use the data collected from his/her clinical interview in previous weeks to write up a case conceptualization. The case conceptualization has 2 parts, the inverted Pyramid Model and the Case Conceptualization Narrative. The Case Conceptualization is where the student moves from describing the problem (diagnosis) to understanding the problem. This assignment should be 1-3 pages in length in current APA format, which includes headings, subheadings, in-text citations, reference section. (CLOs: D, E)

The 3rd formative assignment is the Case Presentation Treatment Plan (CP-TP)  This is the final step in the Case Presentation project for the class. The student will develop a treatment plan, based on the previous data collected, e.g,. assessment, diagnosis, and case conceptualization, that is ethically, culturally, and evidenced/theory based. The treatment plan has a number of component such behaviorally-defined problems, goals, interventions, and outcome measurements. This assignment is 1-3 pages in length in current APA format which includes the use of title page, headings, subheadings, intext citations, reference section. (CLOs: B, D, E, F)

The Case Presentation: Final is where the student will bring together his/her 3 formative assignments (Assessment & Diagnosis, Case Conceptualization, and Treatment Plan) into a final document. Over the course, the student will have received feedback via the instructor and peers. The student will take the feedback along with any other resources, e.g. textbooks, to finalize his/her Case Presentation. This assignment should be 10-12 pages in length in current APA format, which includes a cover page, headings, subheadings, intext citations, and a reference section. (CLOs: A, B, C, D, E F)

This Dispositions Reflection quiz will ask the student to rate him/herself on the nine dispositions required for this program by our accrediting bodies using the following scale:

• Exceeds expectations – I believe I do this exceptionally well.
• Clearly meets expectations – I believe I am able to do this in an appropriate way as expected for graduate students at my current position in the program.
• Adequately meets expectations – I believe I do this but could use improvement and growth in this dispositional area.
• Does not meet expectations – I believe I do not do this well and could use improvement.

This quiz will cover the Learn material for the assigned module: week. This quiz will be open-book/open-notes, contain 9 multiple-choice and 1 essay questions, and will have a 60-minute time limit.

There are a total of 6 content quizzes in the course. The quizzes are based on course textbooks, readings, videos, and other media required for each module. The quizzes are comprehensive, i.e., module 2 quiz will have quiz items from module 1; module 6 quiz may have quiz items from module 1, 2, 3, 4, and 5. The quizzes will cover topic such as clinical interviewing, assessment, diagnosis, case conceptualization, treatment planning, and Christian integration. The student will have unlimited attempts for each quiz. The quizzes are not timed. They can be taken repeatedly over the course. The pedagogical rationale is the student needs to have repeated attempts, “practice,” in recalling and recognizing the course material for application in professional counseling and preparation for state exams for licensure.

This quiz will cover the Learn material for the assigned module: week. This quiz will be open-book/open-notes, contain 24-25 multiple-choice and true/false questions, and will have no time limit. (CLOs: A, B, C, D, E, F, G)

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