Case Formulation Paper

Instructions

Objective: The objective of this assignment is for the student to demonstrate the ability to organize and describe case material using cognitive and behavioral theories.

Assignment: The student should identify a case, either from their field-work or some other helping role to use for the paper. A brief bio-psycho-social-spiritual summary of the case should be provided (2-3 pages) that includes the presenting problem of the case as if it were being placed in a medical chart. Please see the detailed rubric located in the Getting Started section of this course. Using some of the examples used in class as a guide, the student should write up a case formulation in a narrative form (NOT a conceptualization chart). First, explain the target issue using behavioral theory, including the terms and concepts of the theory. Second, explain the target issue using a cognitive theory lens, also using the concepts and terms of the theory. Then using the combined CBT approach, describe the case in a NON-JARGON/CIENT FRIENDLY manner (can be written as a summary to a caregiver or colleague or as if you were speaking directly to the client). The connection between the thoughts, feelings, and behaviors should be clear as the student explains why the person is feeling, thinking and behaving in a way that they present to the worker. Students should follow the rubric located in the Getting Started section of the course. This paper should be no more than 7-8 pages. (Please note that “student” and “worker” are used interchangeably in this description)

Outline for Biopsychosocial-Spiritual Assessment

724 Cognitive Behavioral Theory

I. Referral

How did the client(s) get to the agency? Is the client self-referred, involuntary, or some of

each? What does the client say? What is the context of the agency? What is the purpose

of the referral?

II. Description of the Client

Summarize relevant identifying information including: age, sex, marital and/or partner

status, sexual orientation, race, ethnicity, social class, income source(s), children, health

status, spiritual affiliation, as well as a brief physical description.

III. Presenting Issues and Concerns

How does the client view her/his concerns/issues? How do other people, i.e. family

friends, agency, you or any other relevant individuals view the concerns/issues? When

did these concerns/issues begin? How has the client dealt with these concerns/issues in

the past? What would the client most want help with? Any history of substance abuse?

Current substance use? Suicidal/homicidal ideation? Currently psychotic? Any previous

history of mental health or other agency services? Any medical issues? Military history?

Legal history?

IV. Assessment of Relevant Contextual, Historical Information and

Intrapersonal Factors

A. Current Context: Describe family, work and the social relationships that are relevant

to an understanding of the problem. With whom does the client live? Where does the

client work or go to school or spend significant time? In addition, consider environmental

and social context issues, such as housing, safety of community, access to health services,

issues of discrimination, connections with spiritual or other community organizations,

and any other relevant issues that social workers should consider in assessing the social

context of a client.

B. Historical Influences: Summarize relevant material about clients childhood,

relationships with family of origin, school and work history, and intimate relationships.

C. Coping Strengths and Weaknesses: What are the clients strengths/weaknesses? How

do the above and social institutional resources and obstacles facilitate or inhibit the

clients mastering current issues/concerns? What role do current life cycle tasks play in

relation to the concerns/issues that have been identified? What cultural components may

influence coping styles?

Grading Criteria: The student has

Case Summary: Used the provided biopsychosocial outline and described the client addressed each

area described in the outline (2-3 pages)

Target Issue: In a separate paragraph, clearly identified the target issue (i.e., a behavior, a

feeling, a reaction) including the frequency, duration, intensity, and any other descriptors that

help paint a picture of the main issue. (approximately 1 paragraph)

Behavioral Theory: Explained the target issue from a behavioral theory lens (including

classical/respondent conditioning, operant conditioning, and social learning theory) Use terms

here from the theory (1-1 1/2 pgs.)

Cognitive Theory: Explained the target issue from a cognitive theory lens (use the cognitive

conceptualization diagram and create a narrative from it) – Use terms here from the theory (1-1 1/2

pgs.)

The working hypothesis/case formulation:

Links the formative influences to the current issue is an explanation and NOT a description or

resummary of the case material

Is comprehensive and provides an accurate clinical summation of the relevant issues that are

currently influencing the situation of the client using the CBT framework (connect all three points

of the triangle here integrate the CT and BT sections from above).

Is written in client-friendly language NO jargon

Provides at least one example of the CBT cycle (approximately 34-1 page)

The paper is well written with no errors.