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Introduction to this Assignment

For the purpose of this course, we will use the outline below to
shape our Case Study. A brief description is provided for each element
to help guide you’re planning.

• Introduction
  (Observation): A brief introduction/summary of the case, including some
  basic background of the client and the issues presented.
• Etiology &
  Diagnosis (Interpretation): Discuss the presenting issues, both
  articulated and perceived. Organize the description around sets of
  symptoms that lead to a diagnosis or opinion.
• Treatment Plan
  and Prognosis (Application): Provide action steps and recommendations
  to support the needs of the client. Plan should provide projected
  prognosis.

Perhaps it is the unique perspective of the College or simply just a
smart way to do things, but our worldview and method of study relies on
something called a hermeneutic (herma-new-tick). Now, you can spend tons
of time reading about different perspectives and methods of
hermeneutics and counseling sessions, but we have found the following
outline the most helpful, especially when applied to cases like the one
we will be reviewing. The basic outline, called the Inductive Method,
looks like:

This week we will focus on observation. In observation you major task
is to – well – OBSERVE. Don’t be fooled. While the process sounds easy
(which it is), it is often overlooked. The tendency is to rush to
interpretation, but by doing so we may miss out on important aspects
that can only be recognized through careful observation. That is one
reason good counselors and life coaches take good notes.

We will start the process by asking you to take some notes. You can
decide how best to do this (i.e. paper, electronically, recording,
etc.). It may help to review the Intake Form
first. While these are only used during formal counseling sessions, we
thought it would be beneficial to provide one for this case, since you
have no other background on the client. As you read through, take notes
of things that stand out to you.

Once you have reviewed the intake information, take some time to review the two sessions.

• Session 1
• Session 2 –
  The counseling session continues on with the client moving into being a
  victim of sexual abuse and how that manifested in areas of trust and
  distrust during his journey into adulthood. The therapist would explore
  this with the client in subsequent counseling sessions.

You will want to take notes as you do. We have provided a few
suggestions of what to watch for below. After watching the sessions you
may want to review the intake form once again.

Things to observe:

• 1.   Five W’s – Who. What, When. Where, and Why
• 2.   What does the person look like physically (relaxed, tense, slumped, guarded, etc.)?
• a.   Does this ever change?
• i.   If so, when?
• 3.   Are there any physical behaviors, habits, demonstrations that are notable?
• 4.   Are there common themes, topics, subjects discussed by the client?
• 5.   Are there common or repeated words or phrases?
• 6.   How well does the client identify issues? Does he or she struggle with recollection or articulation?
• 7.   Does the client share information about support structures or ways in which he or she is addressing the issues?
• 8.   Does the client indicate certain individuals as positive or negative influences?
• 9.   Are there contradictions in what the client is saying?
• 10. Are there inconsistencies between what the client is saying and their mood or non-verbal cues?

These are just a few suggestions. Observation is largely determined
by your own perspective and style as a counselor. When you are done,
please type up all of your notes. You will be submitting these along
with your Introduction.

Putting it Together

Having recorded your observations, it is now time to construct an
introduction. In this first section of your Case Study Analysis you fill
provide a summary of your observations and background to the case.
There is no real right or wrong way to do this, as much of what you will
write will be based on your observations. However, this summary should
provide the reader with a concise overview of the case, the client, and
other influencing factors. You can review an example here: Example Introduction

You will need to be careful not to jump to diagnosing the case. There
is a difference between summarizing and diagnosing (which we will do
later in this class). To help illustrate the difference, review the
following:

• Mr. Cantou, a 40-year old male, is suffering from depression.
• Mr. Cantou, a
  40-year old male, describes feelings of isolation, helplessness, and
  irritability. Physically, the client has indicated inconsistent sleep,
  lack of energy, and significant increase in weight.

You will see that the first statement jumps past description
(observation) and moves directly to the diagnosis (interpretation).
While the diagnosis of depression may be correct, it is not yet time to
declare that decision. In the next section, which we will address next
week, we will work on diagnosing. For right now, your task is to provide
a description; a summary of the case.

Using the sample provided above as a reference point, here are a few ideas to help guide your writing process:

• Describe the basic demographic information of the client. This will include information from the videos and the Intake Forms.
• Describe
  the emotional state of the client. Does his mood intensity, vocal tone,
  or physical posture change when discussing different topics?
• Describe the attitude of the client – both in general and toward the situation.
• Describe the willingness and motivation of the client to make change.
• Summarize the main issue discussed by the client.
• Summarize other issues that the client articulates or alludes to.
• Provide some description of the resources and support structure that the client has access to.

Your Introduction should be 1-2 pages. More than that; you are probably over describing. When done, upload two documents:

• 1. Your observation notes
• 2. Your introduction