child counseling case study examples

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

Case Examples

Examples of recommended interventions in the treatment of depression across the lifespan.

Children/Adolescents

A 15-year-old Puerto Rican female

The adolescent was previously diagnosed with major depressive disorder and treated intermittently with supportive psychotherapy and antidepressants. Her more recent episodes related to her parents’ marital problems and her academic/social difficulties at school. She was treated using cognitive-behavioral therapy (CBT).

Chafey, M.I.J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety , 26, 98-103.  https://doi.org/10.1002/da.20457

Sam, a 15-year-old adolescent

Sam was team captain of his soccer team, but an unexpected fight with another teammate prompted his parents to meet with a clinical psychologist. Sam was diagnosed with major depressive disorder after showing an increase in symptoms over the previous three months. Several recent challenges in his family and romantic life led the therapist to recommend interpersonal psychotherapy for adolescents (IPT-A).

Hall, E.B., & Mufson, L. (2009). Interpersonal Psychotherapy for Depressed Adolescents (IPT-A): A Case Illustration. Journal of Clinical Child & Adolescent Psychology, 38 (4), 582-593. https://doi.org/10.1080/15374410902976338

© Society of Clinical Child and Adolescent Psychology (Div. 53) APA, https://sccap53.org/, reprinted by permission of Taylor & Francis Ltd, http://www.tandfonline.com on behalf of the Society of Clinical Child and Adolescent Psychology (Div. 53) APA.

General Adults

Mark, a 43-year-old male

Mark had a history of depression and sought treatment after his second marriage ended. His depression was characterized as being “controlled by a pattern of interpersonal avoidance.” The behavior/activation therapist asked Mark to complete an activity record to help steer the treatment sessions.

Dimidjian, S., Martell, C.R., Addis, M.E., & Herman-Dunn, R. (2008). Chapter 8: Behavioral activation for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 343-362). New York: Guilford Press.

Reprinted with permission from Guilford Press.

Denise, a 59-year-old widow

Denise is described as having “nonchronic depression” which appeared most recently at the onset of her husband’s diagnosis with brain cancer. Her symptoms were loneliness, difficulty coping with daily life, and sadness. Treatment included filling out a weekly activity log and identifying/reconstructing automatic thoughts.

Young, J.E., Rygh, J.L., Weinberger, A.D., & Beck, A.T. (2008). Chapter 6: Cognitive therapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 278-287). New York, NY: Guilford Press.

Nancy, a 25-year-old single, white female

Nancy described herself as being “trapped by her relationships.” Her intake interview confirmed symptoms of major depressive disorder and the clinician recommended cognitive-behavioral therapy. 

Persons, J.B., Davidson, J. & Tompkins, M.A. (2001). A Case Example: Nancy. In Essential Components of Cognitive-Behavior Therapy For Depression (pp. 205-242). Washington, D.C.: American Psychological Association. http://dx.doi.org/10.1037/10389-007

While APA owns the rights to this text, some exhibits are property of the San Francisco Bay Area Center for Cognitive Therapy, which has granted the APA permission for use.

Luke, a 34-year-old male graduate student

Luke is described as having treatment-resistant depression and while not suicidal, hoped that a fatal illness would take his life or that he would just disappear. His treatment involved mindfulness-based cognitive therapy, which helps participants become aware of and recharacterize their overwhelming negative thoughts. It involves regular practice of mindfulness techniques and exercises as one component of therapy.

Sipe, W.E.B., & Eisendrath, S.J. (2014). Chapter 3 — Mindfulness-Based Cognitive Therapy For Treatment-Resistant Depression. In R.A. Baer (Ed.), Mindfulness-Based Treatment Approaches (2nd ed., pp. 66-70). San Diego: Academic Press.

Reprinted with permission from Elsevier.

Sara, a 35-year-old married female

Sara was referred to treatment after having a stillbirth. Sara showed symptoms of grief, or complicated bereavement, and was diagnosed with major depression, recurrent. The clinician recommended interpersonal psychotherapy (IPT) for a duration of 12 weeks.

Bleiberg, K.L., & Markowitz, J.C. (2008). Chapter 7: Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: a treatment manual (4th ed., pp. 315-323). New York, NY: Guilford Press.

Peggy, a 52-year-old white, Italian-American widow

Peggy had a history of chronic depression, which flared during her husband’s illness and ultimate death. Guilt was a driving factor of her depressive symptoms, which lasted six months after his death. The clinician treated Peggy with psychodynamic therapy over a period of two years.

Bishop, J., & Lane , R.C. (2003). Psychodynamic Treatment of a Case of Grief Superimposed On Melancholia. Clinical Case Studies , 2(1), 3-19. https://doi.org/10.1177/1534650102239085

Several case examples of supportive therapy

Winston, A., Rosenthal, R.N., & Pinsker, H. (2004). Introduction to Supportive Psychotherapy . Arlington, VA : American Psychiatric Publishing.

Older Adults

Several case examples of interpersonal psychotherapy & pharmacotherapy

Miller, M. D., Wolfson, L., Frank, E., Cornes, C., Silberman, R., Ehrenpreis, L.…Reynolds, C. F., III. (1998). Using Interpersonal Psychotherapy (IPT) in a Combined Psychotherapy/Medication Research Protocol with Depressed Elders: A Descriptive Report With Case Vignettes. Journal of Psychotherapy Practice and Research , 7(1), 47-55.

• Children's mental health case studies
• Food, health and nutrition
• Mental wellbeing
• Mental health

Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
• Shows the needs of a child at specific stages of development.
• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
• Practice-based.
• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
• Stigma can prevent people from seeking help.
• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
• Rural mental health services.
• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
• Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

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• v.16(5-6); 2019 May 1

PLAY THERAPY: An Illustrative Case

Play therapy is a valuable tool in psychotherapy with children that has been shown to be effective in the treatment of mental illness and behavioral problems. In play therapy, the therapist follows the child’s lead through play, and the child expresses thoughts and feelings that might be difficult to communicate otherwise. The therapist creates a space to allow children to practice play and pretend, thus allowing the therapeutic alliance to develop. The eight tenets of play therapy are discussed, and an illustrative case vignette that demonstrates the common ego defenses and developmental hurdles that can be addressed in play therapy is presented.

Play has been recognized by the United Nations Human Rights Council as a right of every child because it is critical to human physical, emotional, social, and cognitive development. 1 Play is vital to healthy brain development. 2 The foundation of a secure caregiver relationship is critical to the trajectory of childhood development and is often mediated through the act of shared play. 2 Play is the mechanism by which children learn how to interact with the world around them and begin to understand social relationships. It is a way to learn and explore the world in a safe environment while mastering new competencies.

According to Piaget, children below the age of 11 years often lack the full capability for abstract thought, which is necessary for meaningful verbal expression. 3 Children 10 years of age or younger, who are in the preoperational stage or concrete operational stage of cognitive development, are more likely to exhibit concrete thinking and have trouble verbalizing difficult emotions. As Axline said, “play is the child’s natural medium of self-expression.” 4 In contrast to adults, who are better able to express feelings through words, children are more likely to communicate feelings through play. The central tenet of play therapy is that children use play to communicate unconscious conflicts and feelings through displacement with the therapist. Play therapy allows children to directly or symbolically act out their thoughts and emotions. 5 The following clinical vignette illustrates the core facets of play therapy and play therapy techniques.

CASE VIGNETTE

SH was a seven-year-old girl referred to therapy due to increased anxiety and school refusal. Approximately six months previously, her grandmother died suddenly, and, shortly after, her father seriously injured his shoulder at work. She began exhibiting symptoms of excessive worry, somatic symptoms, crying spells, and nightmares. She began refusing to go to school and cried when forced to separate from her parents. She had frequent nightmares of monsters chasing her. She refused to sleep in her own room and checked the locks on the doors multiple times before finally going to bed. Prior to her grandmother’s death, SH was calm but slow to warm in new situations.

PRACTICE POINT: PRINCIPLES OF PLAY THERAPY

At seven years old, SH is in the ideal age range for play therapy because she is at a developmental age where play is the language she uses to communicate. Axline, one of the first researchers in the field of play therapy, emphasized a child-centered and nondirective approach to therapy. 4 She developed Child-centered Play Therapy in 1947. The eight guiding principles of play therapy include: 1) forming a warm, friendly, therapeutic alliance with the child, 2) accepting the child, 3) establishing a therapeutic environment that fosters permissiveness, 4) recognizing and reflecting back the feelings the child expresses, 5) recognizing and respecting the child’s ability to solve their own problems, 6) being nondirective and letting the child lead the therapy, 7) recognizing that therapy is a gradual process, and 8) establishing limitations to anchor therapy in reality. 4 These principles are essential to follow during therapy, especially during the first visit when it is critical to foster a safe and comfortable environment for the child.

CASE VIGNETTE, CONTINUED

At her initial appointment, SH refused to separate from her mother. She sat close to her mother on the couch, holding her hand tightly, as her mother began discussing recent events. As the session progressed, she started looking around the room and appeared to be looking at all of the toys.

The therapist smiled warmly at SH and stated, “You can play with any of these toys whenever you like.”

When addressed directly by her therapist, SH buried her face in her mother’s arm. A few minutes later, after the therapist returned to conversing with the mother, SH slowly freed her hand and slid off of the couch. She started walking around the room and briefly stopped to look at each toy until she settled in front of a large dollhouse. She started to inspect each doll while looking over her shoulder at the therapist and her mother, before she picked up each one. At the end of the session, her therapist and her mother helped SH clean up the toys and showered her with praise.

PRACTICE POINT: THE INITIAL CONSULTATION

Each phase of play therapy has integral tasks, including those that shape the patient–physician relationship, those that facilitate reflection and change, and those that pertain to the work with the parent or guardian. 6 One of the most important goals of the first play therapy session is to create a holding environment where the child feels safe and comfortable to engage in imaginative play. Parents and guardians are often involved during the first few sessions, depending on the child’s ability to separate. During the first session, it is important to set up the frame of therapy by discussing scheduling, routines for treatment, roles within the therapy relationship, and stages of treatment. By allowing the child to explore the toys in the room, this encourages playful expression, while providing must-needed limits and rules to maintain safety and order and informing the evaluation. This also provides the parent and child with expectations and consistency. During the first phase of treatment, which includes the initial session, evaluation, and formulation, the therapist should be sensitive to the needs of the parent or guardian and the child. This includes paying close attention to temperament as illustrated in the vignette above. The therapist noted SH appeared anxious and slow to warm, so the therapist cautiously engaged her and allowed her the space to explore the room when she was ready.

When SH arrived for her fourth session, she appeared nervous at first, refusing to let go of her mother’s hand. Thus far, she had been unable to separate from her mother during therapy. However, this time, as SH and her mother walked into the therapy room, SH let go of her mother’s hand and sat in front of the dollhouse. A few minutes later, the mother told SH she would be in the waiting room if SH needed her, and then slipped out of the room. SH continued playing with the dolls quietly and did not appear distressed. She eventually cradled one of the dolls, created a sling out of tissues, and wrapped it around the doll’s right shoulder. She proceeded to lay the doll in bed and cover it with a blanket.

PRACTICE POINT: THE TREATMENT PHASE

As treatment progresses, it is necessary for the child to feel comfortable enough to separate from the parent or guardian. The child should be allowed to decide what to do in each session. The therapist is nondirective, and the child is in control of the direction of play. This maximizes the child’s ability to express internal and external conflicts more freely and take ownership of treatment. Understanding the ego defense mechanism of displacement is essential to play therapy. Displacement is the idea that feelings connected with a person or situation are displaced onto another person or object, which is safer than expressing the real conflict verbally or physically. Closely related to this is the therapeutic aspect of fantasy. A child is able to express thoughts and wishes through playing pretend without any repercussions. Thoughts and emotions that might be socially unacceptable in real life or intolerable due to the child’s developmental phase are able to be displaced onto toys and experienced without any fear of consequences. For example, a child who is angry with his mother might act out his emotions by pretending that a toy character physically attacks another toy. In our vignette, SH was displacing conflicting feelings about her father onto the doll through fantasy by comforting and “fixing” the doll’s shoulder.

After placing the doll in bed, SH turned toward her therapist and handed her a doll. She stated, “This is the baby. The baby needs to get ready for school or she’s going to be late.” SH then picked up another doll, announced she was the mother and stated, “You are going to have to be a big girl and get ready by yourself now. I can’t help you. Hurry up or you will be late for school.” SH walked her doll into the bedroom and started to care for the injured doll.

Her therapist stated, “The baby probably feels scared and alone getting ready by herself. I wonder if she’s scared to leave her dad and go to school.” SH suddenly grabbed the injured doll and threw it across the room where it landed behind the couch.

Her therapist stated, “You look very angry right now. Sometimes when I get angry I want to throw things too. We have to be careful and keep each other safe. How can we show our anger and stay safe?”

PRACTICE POINT: CONTINUUM OF INTERVENTIONS

As treatment progresses, the displacement of the child’s internal world onto the play gives the therapist the opportunity to promote reflection and enact change. The child’s expression should always be validated to minimize disruption of the play. Specific therapy interventions range from passive to expressive, and the use of specific interventions are based upon the child’s ego strength and reflective capacity. 7 , 8 A supportive intervention can be promoting play where engaging in play itself is the goal. 6 This was seen during the first session with SH. In our vignette, SH’s therapist attempted to use an expressive intervention by commenting on the internal feelings of the baby, who is a representation of SH. It was clear from SH’s response she could not tolerate the intervention. As the therapist, it is important to only interpret directly from the play when the child is ready to hear the interpretation and monitor for signs the child is ready for an expressive intervention, which connects fantasy with conflicting reality. In any therapy modality, the timing of interpretations is important. In our vignette, if the child was not ready to hear the interpretation, the play would often shut down quickly due to the development of resistance. To foster a permissive environment, it is vital to make a safe play space and respect the child’s defenses. In response, her therapist commented on her current affect to identify emotion, promote reflection, and establish a connection between feelings and behavior. This, over time, would promote emotion regulation and more adaptive responses to intense emotion. It also served to ground SH and bring her back to reality from fantasy in a way she accepted and set limits to provide safety. By asking SH to problem solve the therapist promoted ownership of her treatment, which would lead to a sense of mastery and accomplishment.

SH returned for Session 12 of therapy. The father doll continued to lie in bed with his sling and a blanket over him. During previous sessions, SH played the role of the mother, who continued to ignore the baby.

This session, the therapist commented, “The baby wishes her dad could play with her again. She loves her mom and wishes she would play with her, but she also misses her dad and wants him to be okay. She worries if she asks mom for attention it will hurt her dad.”

SH picked up the mom doll and stated, “I feel sad and miss you too.” She then took the baby doll to the park, fed her dinner, and helped her get ready for bed. In response, her therapist stated, “Thanks for playing with me. That was so much fun, and Dad is still okay.”

PRACTICE POINT: WORKING IN THE DISPLACEMENT

During play, the therapist follows the child’s lead. In our vignette, SH allowed the therapist to be actively engaged in the play by handing the therapist the doll. The therapist can then either play an active role in the play by speaking as a character, or, in our case, can be an outside observer commenting on the actions or feelings of the character. The therapist in our vignette took on the role of an outside observer and commented on how the baby must be feeling. Imaginative play allows children to have a sense of control over situations that are often experienced passively in real life. SH had no control over her father’s injury, the loss of her grandmother, or the subsequent stress it caused her family. In this play scenario, SH demonstrated the concept of turning passive into active. 7 She first responded to this lack of control by taking an active role in play through comforting and “fixing” the doll. SH then turned her passive role as a scared child who cannot help her injured father and wished her mother would take care of her into an active role by playing her mother. She felt scared and anxious in real life, but in play, she was able to be the adult who took care of her and her family. SH was unable to verbalize the underlying reasons for her anxiety and fear. However, displacement allowed her to express unwanted feelings through play, even allowing the therapist to engage actively in play as well. With the help of her therapist, she was able to attain mastery over the situation by identifying the internal conflict between wanting to be taken care of by her mother and fearing this desire would result in further harm of her father.

Since Axline’s initial qualitative research in the field, additional research providing evidence for the efficacy of play therapy has been conducted. Play therapy has been shown to be equally effective for mental illnesses and behavioral problems. 9 A meta-analysis of 42 controlled studies examining the efficacy of play therapy showed a mean effect size of 0.66, as well as a strong positive relationship between therapeutic effectiveness and parental inclusion in therapy. 10 The study also examined the duration of therapy in relation to therapeutic effectiveness and found the maximum effect occurred after 30 sessions. 10

A second meta-analysis of 93 research studies conducted in 2005 by Bratton et al 11 examined the efficacy of play therapy and found a strong mean effect size of 0.8. Parental involvement also was strongly related to therapeutic effectiveness. 11 The maximum effect of treatment was found to occur between 35 and 40 sessions. Play therapy was found to be beneficial no matter the age or sex of the patient included in the study (mean age of 7 years). However, the meta-analysis did not take into account the ethnicity of a patient. In addition, the study showed a significant effect size for utilizing play therapy for both internalizing and externalizing problems. 11

Play therapy is a developmentally appropriate approach to treatment in children and has been shown to have a beneficial, therapeutic effect. By creating a safe holding environment in the playroom, children can communicate through fantasy, imagination, and displacement. This allows them to separate reality from fantasy within a therapeutic space. Over time, through carefully planned interventions, the therapist can connect fantasy and reality through the developmentally appropriate medium of play, empower the child through ownership of treatment, and provide the corrective experience that has the potential for lasting change.

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Article Contents

Literature review, alive program, implications for school social work practice.

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Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program

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Jason Scott Frydman, Christine Mayor, Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program, Children & Schools , Volume 39, Issue 4, October 2017, Pages 238–247, https://doi.org/10.1093/cs/cdx017

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Middle-school-age children are faced with a variety of developmental tasks, including the beginning phases of individuation from the family, building peer groups, social and emotional transitions, and cognitive shifts associated with the maturation process. This article summarizes how traumatic events impair and complicate these developmental tasks, which can lead to disruptive behaviors in the school setting. Following the call by Walkley and Cox for more attention to be given to trauma-informed schools, this article provides detailed information about the Animating Learning by Integrating and Validating Experience program: a school-based, trauma-informed intervention for middle school students. This public health model uses psychoeducation, cognitive differentiation, and brief stress reduction counseling sessions to facilitate socioemotional development and academic progress. Case examples from the authors’ clinical work in the New Haven, Connecticut, urban public school system are provided.

Within the U.S. school system there is growing awareness of how traumatic experience negatively affects early adolescent development and functioning ( Chanmugam & Teasley, 2014 ; Perfect, Turley, Carlson, Yohannan, & Gilles, 2016 ; Porche, Costello, & Rosen-Reynoso, 2016 ; Sibinga, Webb, Ghazarian, & Ellen, 2016 ; Turner, Shattuck, Finkelhor, & Hamby, 2017 ; Woodbridge et al., 2016 ). The manifested trauma symptoms of these students have been widely documented and include self-isolation, aggression, and attentional deficit and hyperactivity, producing individual and schoolwide difficulties ( Cook et al., 2005 ; Iachini, Petiwala, & DeHart, 2016 ; Oehlberg, 2008 ; Sajnani, Jewers-Dailley, Brillante, Puglisi, & Johnson, 2014 ). To address this vulnerability, school social workers should be aware of public health models promoting prevention, data-driven investigation, and broad-based trauma interventions ( Chafouleas, Johnson, Overstreet, & Santos, 2016 ; Johnson, 2012 ; Moon, Williford, & Mendenhall, 2017 ; Overstreet & Chafouleas, 2016 ; Overstreet & Matthews, 2011 ). Without comprehensive and effective interventions in the school setting, seminal adolescent developmental tasks are at risk.

This article follows the twofold call by Walkley and Cox (2013) for school social workers to develop a heightened awareness of trauma exposure's impact on childhood development and to highlight trauma-informed practices in the school setting. In reference to the former, this article will not focus on the general impact of toxic stress, or chronic trauma, on early adolescents in the school setting, as this work has been widely documented. Rather, it begins with a synthesis of how exposure to trauma impairs early adolescent developmental tasks. As to the latter, we will outline and discuss the Animating Learning by Integrating and Validating Experience (ALIVE) program, a school-based, trauma-informed intervention that is grounded in a public health framework. The model uses psychoeducation, cognitive differentiation, and brief stress reduction sessions to promote socioemotional development and academic progress. We present two clinical cases as examples of trauma-informed, school-based practice, and then apply their experience working in an urban, public middle school to explicate intervention theory and practice for school social workers.

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

Traumatic experiences may create difficulty with developing and differentiating another person's point of view (that is, mentalization) due to the formation of rigid cognitive schemas that dictate notions of self, others, and the external world ( Frydman & McLellan, 2014 ). For early adolescents, the ability to diversify a single perspective with complexity is central to modulating affective experience. Without the capacity to diversify one's perspective, there is often difficulty differentiating between a nonthreatening current situation that may harbor reminders of the traumatic experience and actual traumatic events. Incumbent on the school social worker is the need to help students understand how these conflicts may trigger a memory of harm, abandonment, or loss and how to differentiate these past memories from the present conflict. This is of particular concern when these reactions are conflated with more common middle school behaviors such as withdrawing, blaming, criticizing, and gossiping ( Card, Stucky, Sawalani, & Little, 2008 ).

Encouraging cognitive discrimination is particularly meaningful given that the second social developmental task for early adolescents is the re-orientation of their primary relationships with family toward peers ( Henderson & Thompson, 2010 ). This shift may become complicated for students facing traumatic stress, resulting in a stunted movement away from familiar connections or a displacement of dysfunctional family relationships onto peers. For example, in the former, a student who has witnessed and intervened to protect his mother from severe domestic violence might believe he needs to sacrifice himself and be available to his mother, forgoing typical peer interactions. In the latter, a student who was beaten when a loud, intoxicated family member came home might become enraged, anxious, or anticipate violence when other students raise their voices.

Cognitive Development and Emotional Regulation

During normative early adolescent development, the prefrontal cortex undergoes maturational shifts in cognitive and emotional functioning, including increased impulse control and affect regulation ( Wigfield, Lutz, & Wagner, 2005 ). However, these developmental tasks can be negatively affected by chronic exposure to traumatic events. Stressful situations often evoke a fear response, which inhibits executive functioning and commonly results in a fight-flight-freeze reaction. If a student does not possess strong anxiety management skills to cope with reminders of the trauma, the student is prone to further emotional dysregulation, lowered frustration tolerance, and increased behavioral problems and depressive symptoms ( Iachini et al., 2016 ; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ).

Typical cognitive development in early adolescence is defined by the ambiguity of a transitional stage between childhood remedial capacity and adult refinement ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Casey and Caudle (2013) found that although adolescents performed equally as well as, if not better than, adults on a self-control task when no emotional information was present, the introduction of affectively laden social cues resulted in diminished performance. The developmental challenge for the early adolescent then is to facilitate the coordination of this ever-shifting dynamic between cognition and affect. Although early adolescents may display efficient and logically informed behaviors, they may struggle to sustain these behaviors, especially in the presence of emotional stimuli ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Because trauma often evokes an emotional response ( Johnson & Lubin, 2015 ), these findings insinuate that those early adolescents who are chronically exposed will have ongoing regulation difficulties. Further empirical findings considering the cognitive effects of trauma exposure on the adolescent brain have highlighted detriments in working memory, inhibition, memory, and planning ability ( Moradi, Neshat Doost, Taghavi, Yule, & Dalgleish, 1999 ).

Using a Public Health Framework for School-Based, Trauma-Informed Services

The need for a more informed and comprehensive approach to addressing trauma within the schools has been widely articulated ( Chafouleas et al., 2016 ; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011 ; Jaycox, Kataoka, Stein, Langley, & Wong, 2012 ; Overstreet & Chafouleas, 2016 ; Perry & Daniels, 2016 ). Overstreet and Matthews (2011) suggested that using a public health model to address trauma in schools will promote prevention, early identification, and data-driven investigation and yield broad-based intervention on a policy and communitywide level. A public health approach focuses on developing interventions that address the underlying causal processes that lead to social, emotional, and cognitive maladjustment. Opening the dialogue to the entire student body, as well as teachers and administrators, promotes inclusion and provides a comprehensive foundation for psychoeducation, assessment, and prevention.

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

Note: ALIVE = Animating Learning by Integrating and Validating Experience.

Psychoeducation

The classroom is a place traditionally dedicated to academic pursuits; however, it also serves as an indicator of trauma's impact on cognitive functioning evidenced by poor grades, behavioral dysregulation, and social turbulence. ALIVE practitioners conduct weekly trauma-focused dialogues in the classroom to normalize conversations addressing trauma, to recruit and rehearse more adaptive cognitive skills, and to engage in an insight-oriented process ( Sajnani et al., 2014 ).

Using a parable as a projective tool for identification and connection, the model helps students tolerate direct discussions about adverse experiences. The ALIVE practitioner begins each academic year by telling the parable of a woman named Miss Kendra, who struggled to cope with the loss of her 10-year-old child. Miss Kendra is able to make meaning out of her loss by providing support for schoolchildren who have encountered adverse experiences, serving as a reminder of the strength it takes to press forward after a traumatic event. The intention of this parable is to establish a metaphor for survival and strength to fortify the coping skills already held by trauma-exposed middle school students. Furthermore, Miss Kendra offers early adolescents an opportunity to project their own needs onto the story, creating a personalized figure who embodies support for socioemotional growth.

Following this parable, the students’ attention is directed toward Miss Kendra's List, a poster that is permanently displayed in the classroom. The list includes a series of statements against adolescent maltreatment, comprehensively identifying various traumatic stressors such as witnessing domestic violence; being physically, verbally, or sexually abused; and losing a loved one to neighborhood violence. The second section of the list identifies what may happen to early adolescents when they experience trauma from emotional, social, and academic perspectives. The practitioner uses this list to provide information about the nature and impact of trauma, while modeling for students and staff the ability to discuss difficult experiences as a way of connecting with one another with a sense of hope and strength.

Furthermore, creating a dialogue about these issues with early adolescents facilitates a culture of acceptance, tolerance, and understanding, engendering empathy and identification among students. This fostering of interpersonal connection provides a reparative and differentiated experience to trauma ( Hartling & Sparks, 2008 ; Henderson & Thompson, 2010 ; Johnson & Lubin, 2015 ) and is particularly important given the peer-focused developmental tasks of early adolescence. The positive feelings evoked through classroom-based conversation are predicated on empathic identification among the students and an accompanying sense of relief in understanding the scope of trauma's impact. Furthermore, the consistent appearance of and engagement by the ALIVE practitioner, and the continual presence of Miss Kendra's list, effectively counters traumatically informed expectations of abandonment and loss while aligning with a public health model that attends to the impact of trauma on a regular, systemwide basis.

Participatory and Somatic Indicators for Informal Assessment during the Psychoeducation Component of the ALIVE Intervention

Notes: ALIVE = Animating Learning by Integrating and Validating Experience. Examples are derived from authors’ clinical experiences.

In addition to behavioral symptoms, the content of conversation is considered. All practitioners in the ALIVE program are mandated reporters, and any content presented that meets criteria for suspicion of child maltreatment is brought to the attention of the school leadership and ALIVE director. According to Johnson (2012) , reports of child maltreatment to the Connecticut Department of Child and Family Services have actually decreased in the schools where the program has been implemented “because [the ALIVE program is] catching problems well before they have risen to the severity that would require reporting” (p. 17).

Case Example 1

The following demonstrates a middle school classroom psychoeducation session and assessment facilitated by an ALIVE practitioner (the first author). All names and identifying characteristics have been changed to protect confidentiality.

Ms. Skylar's seventh grade class comprised many students living in low-income housing or in a neighborhood characterized by high poverty and frequent criminal activity. During the second week of school, I introduced myself as a practitioner who was here to speak directly about difficult experiences and how these instances might affect academic functioning and students’ thoughts about themselves, others, and their environment.

After sharing the Miss Kendra parable and list, I invited the students to share their thoughts about Miss Kendra and her journey. Tyreke began the conversation by wondering whether Miss Kendra lost her child to gun violence, exploring the connection between the list and the story and his own frequent exposure to neighborhood shootings. To transition a singular connection to a communal one, I asked the students if this was a shared experience. The majority of students nodded in agreement. I referred the students back to the list and asked them to identify how someone's school functioning or mood may be affected by ongoing neighborhood gun violence. While the students read the list, I actively monitored reactions and scanned for inattention and active avoidance. Performing both active facilitation of discussion and monitoring students’ reactions is critical in accomplishing the goals of providing quality psychoeducation and identifying at-risk students for intervention.

After inspection, Cleo remarked that, contrary to a listed outcome on Miss Kendra's list, neighborhood gun violence does not make him feel lonely; rather, he “doesn't care about it.” Slumped down in his chair, head resting on his crossed arms on the desk in front of him, Cleo's body language suggested a somatized disengagement. I invited other students to share their individual reactions. Tyreke agreed that loneliness is not the identified affective experience; rather, for him, it's feeling “mad or scared.” Immediately, Greg concurred, expressing that “it makes me more mad, and I think about my family.”

Encouraging a variety of viewpoints, I stated, “It sounds like it might make you mad, scared, and may even bring up thoughts about your family. I wonder why people have different reactions?” Doing so moved the conversation into a phase of deeper reflection, simultaneously honoring the students’ voiced experience while encouraging critical thinking. A number of students responded by offering connections to their lives, some indicating they had difficulty identifying feelings. I reflected back, “Sometimes people feel something, but can't really put their finger on it, and sometimes they know exactly how they feel or who it makes them think about.”

I followed with a question: “How do you think it affects your schoolwork or feelings when you're in school?” Greg and Natalia both offered that sometimes difficult or confusing thoughts can consume their whole day, even while in class. Sharon began to offer a related comment when Cleo interrupted by speaking at an elevated volume to his desk partner, Tyreke. The two began to snicker and pull focus. By the time they gained the class's full attention, Cleo was openly laughing and pushing his chair back, stating, “No way! She DID!? That's crazy”; he began to stand up, enlisting Tyreke in the process. While this disruption may be viewed as a challenge to the discussion, it is essential to understand all behavior in context of the session's trauma content. Therefore, Cleo's outburst was interpreted as a potential avenue for further exploration of the topic regarding gun violence and difficulties concentrating. In turn, I posed this question to the class: “Should we talk about this stuff? I wonder if sometimes people have a hard time tolerating it. Can anybody think of why it might be important? Sharon, I think you were saying something about this.” While Sharon continued to share, Cleo and Tyreke gradually shifted their attention back to the conversation. I noted the importance of an individual follow-up with Cleo.

Natalia jumped back in the conversation, stating, “I think we talk about stuff like this so we know about it and can help people with it.” I checked in with the rest of the class about this strategy for coping with the impact of trauma exposure on school functioning: “So it sounds like these thoughts have a pretty big impact on your day. If that's the case, how do you feel less worried or mad or scared?” Marta quickly responded, “You could talk to someone.” I responded, “Part of my job here is to be a person to talk to one-on-one about these things. Hopefully, it will help you feel better to get some of that stuff off your chest.” The students nodded, acknowledging that I would return to discuss other items on the list and that there would be opportunities to check in with me individually if needed.

On reflection, Cleo's disruption in the discussion may be attributed to his personal difficulty emotionally managing intrusive thoughts while in school. This clinical assumption was not explicitly named in the moment, but was noted as information for further individual follow-up. When I met individually with Cleo, Cleo reported that his cousin had been shot a month ago, causing him to feel confused and angry. I continued to work with him individually, which resulted in a reduction of behavioral disruptions in the classroom.

In the preceding case example, the practitioner performed a variety of public health tasks. Foremost was the introduction of how traumatic experience may affect individuals and their relationships with others and their role as a student. Second, the practitioner used Miss Kendra and her list as a foundational mechanism to ground the conversation and serve as a reference point for the students’ experience. Finally, the practitioner actively monitored individual responses to the material as a means of identifying students who may require more support. All three of these processes are supported within the public health framework as a means toward assessment and early intervention for early adolescents who may be exposed to trauma.

Individualized Stress Reduction Intervention

Students are seen for individualized support if they display significant externalizing or internalizing trauma-related behavior. Students are either self-referred; referred by a teacher, administrator, or staff member; or identified by an ALIVE practitioner. Following the principle of immediate engagement based on emergent traumatic material, individual sessions are brief, lasting only 15 to 20 minutes. Using trauma-centered psychotherapy ( Johnson & Lubin, 2015 ), a brief inquiry addressing the current problem is conducted to identify the trauma trigger connected to the original harm, fostering cognitive discrimination. Conversation about the adverse experience proceeds in a calm, direct way focusing on differentiating between intrusive memories and the current situation at school ( Sajnani et al., 2014 ). Once the student exhibits greater emotional regulation, the ALIVE practitioner returns the student to the classroom in a timely manner and may provide either brief follow-up sessions for preventive purposes or, when appropriate, refer the student to more regular, clinical support in or out of the school.

Case Example 2

The following case example is representative of the brief, immediate, and open engagement with traumatic material and encouragement of cognitive discrimination. This intervention was conducted with a sixth grade student, Jacob (name and identifying information changed to ensure confidentiality), by an ALIVE practitioner (the second author).

I found Jacob in the hallway violently shaking a trash can, kicking the classroom door, and slamming his hands into the wall and locker. His teacher was standing at the door, distressed, stating, “Jacob, you need to calm down and go to the office, or I'm calling home!” Jacob yelled, “It's not fair, it was him, not me! I'm gonna fight him!” As I approached, I asked what was making him so angry, but he said, “I don't want to talk about it.” Rather than asking him to calm down or stop slamming objects, I instead approached the potential memory agitating him, stating, “My guess is that you are angry for a very good reason.” Upon this simple connection, he sighed and stopped kicking the trash can and slamming the wall. Jacob continued to demonstrate physical and emotional activation, pacing the hallway and making a fist; however, he was able to recount putting trash in the trash can when a peer pushed him from behind, causing him to yell. Jacob explained that his teacher heard him yelling and scolded him, making him more mad. Jacob stated, “She didn't even know what happened and she blamed me. I was trying to help her by taking out all of our breakfast trash. It's not fair.”

The ALIVE practitioner listens to students’ complaints with two ears, one for the current complaint and one for affect-laden details that may be connected to the original trauma to inquire further into the source of the trigger. Affect-laden details in case example 2 include Jacob's anger about being blamed (rather than toward the student who pushed him), his original intention to help, and his repetition of the phrase “it's not fair.” Having met with Jacob previously, I was aware that his mother suffers from physical and mental health difficulties. When his mother is not doing well, he (as the parentified child) typically takes care of the household, performing tasks like cooking, cleaning, and helping with his two younger siblings and older autistic brother. In the past, Jacob has discussed both idealizing his mother and holding internalized anger that he rarely expresses at home because he worries his anger will “make her sick.”

I know sometimes when you are trying to help mom, there are times she gets upset with you for not doing it exactly right, or when your brothers start something, she will blame you. What just happened sounds familiar—you were trying to help your teacher by taking out the garbage when another student pushed you, and then you were the one who got in trouble.

Jacob nodded his head and explained that he was simply trying to help.

I moved into a more detailed inquiry, to see if there was a more recent stressor I was unaware of. When I asked how his mother was doing this week, Jacob revealed that his mother's health had deteriorated and his aunt had temporarily moved in. Jacob told me that he had been yelled at by both his mother and his aunt that morning, when his younger brother was not ready for school. I asked, “I wonder if when the student pushed you it reminded you of getting into trouble because of something your little brother did this morning?” Jacob nodded. The displacement was clear: He had been reminded of this incident at school and was reacting with anger based on his family dynamic, and worries connected to his mother.

My guess is that you were a mix of both worried and angry by the time you got to school, with what's happening at home. You were trying to help with the garbage like you try to help mom when she isn't doing well, so when you got pushed it was like your brother being late, and then when you got blamed by your teacher it was like your mom and aunt yelling, and it all came flooding back in. The problem is, you let out those feelings here. Even though there are some similar things, it's not totally the same, right? Can you tell me what is different?

Jacob nodded and was able to explain that the other student was probably just playing and did not mean to get him into trouble, and that his teacher did not usually yell at him or make him worried. Highlighting this important differentiation, I replied, “Right—and fighting the student or yelling at the teacher isn't going to solve this, but more importantly, it isn't going to make your mom better or have your family go any easier on you either.” Jacob stated that he knew this was true.

I reassured Jacob that I could help him let out those feelings of worry and anger connected to home so they did not explode out at school and planned to meet again. Jacob confirmed that he was willing to do that. He was able to return to the classroom without incident, with the entire intervention lasting less than 15 minutes.

In case example 2, the practitioner was available for an immediate engagement with disturbing behaviors as they were happening by listening for similarities between the current incident and traumatic stressors; asking for specific details to more effectively help Jacob understand how he was being triggered in school; providing psychoeducation about how these two events had become confused and aiding him in cognitively differentiating between the two; and, last, offering to provide further support to reduce future incidents.

Germane to the practice of school social work is the ability to work flexibly within a public health model to attend to trauma within the school setting. First, we suggest that a primary implication for school social workers is not to wait for explicit problems related to known traumatic experiences to emerge before addressing trauma in the school, but, rather, to follow a model of prevention-assessment-intervention. School social workers are in a unique position within the school system to disseminate trauma-informed material to both students and staff in a preventive capacity. Facilitating this implementation will help to establish a tone and sharpened focus within the school community, norming the process of articulating and engaging with traumatic material. In the aforementioned classroom case example, we have provided a sample of how school social workers might work with entire classrooms on a preventive basis regarding trauma, rather than waiting for individual referrals.

Second, in addition to functional behavior assessments and behavior intervention plans, school social workers maintain a keen eye for qualitative behavioral assessment ( National Association of Social Workers, 2012 ). Using this skill set within a trauma-informed model will help to identify those students in need who may be reluctant or resistant to explicitly ask for help. As called for by Walkley and Cox (2013) , we suggest that using the information presented in Table 1 will help school social workers understand, identify, and assess the impact of trauma on early adolescent developmental tasks. If school social workers engage on a classroom level in trauma psychoeducation and conversations, the information in Table 3 may assist with assessment of children and provide a basis for checking in individually with students as warranted.

Third, school social workers are well positioned to provide individual targeted, trauma-informed interventions based on previous knowledge of individual trauma and through widespread assessment ( Walkley & Cox, 2013 ). The individual case example provides one way of immediately engaging with students who are demonstrating trauma-based behaviors. In this model, school social workers engage in a brief inquiry addressing the current trauma to identify the trauma trigger, discuss the adverse experience in a calm but direct way, and help to differentiate between intrusive memories and the current situation at school. For this latter component, the focus is on cognitive discrimination and emotional regulation so that students can reengage in the classroom within a short time frame.

Fourth, given social work's roots in collaboration and community work, school social workers are encouraged to use a systems-based approach in partnering with allied practitioners and institutions ( D'Agostino, 2013 ), thus supporting the public health tenet of establishing and maintaining a link to the wider community. This may include referring students to regular clinical support in or out of the school. Although the implementation of a trauma-informed program will vary across schools, we suggest that school social workers have the capacity to use a public health school intervention model to ecologically address the psychosocial and behavioral issues stemming from trauma exposure.

As increasing attention is being given to adverse childhood experiences, a tiered approach that uses a public health framework in the schools is necessitated. Nevertheless, there are some limitations to this approach. First, although the interventions outlined here are rooted in prevention and early intervention, there are times when formal, intensive treatment outside of the school setting is warranted. Second, the ALIVE program has primarily been implemented by ALIVE practitioners; the results from piloting this public health framework in other school settings with existing school personnel, such as school social workers, will be necessary before widespread replication.

The public health framework of prevention-assessment-intervention promotes continual engagement with middle school students’ chronic exposure to traumatic stress. There is a need to provide both broad-based and individualized support that seeks to comprehensively ameliorate the social, emotional, and cognitive consequences on early adolescent developmental milestones associated with traumatic experiences. We contend that school social workers are well positioned to address this critical public health issue through proactive and widespread psychoeducation and assessment in the schools, and we have provided case examples to demonstrate one model of doing this work within the school day. We hope that this article inspires future writing about how school social workers individually and systemically address trauma in the school system. In alignment with Walkley and Cox (2013) , we encourage others to highlight their practice in incorporating trauma-informed, school-based programming in an effort to increase awareness of effective interventions.

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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.

CASE REPORT article

Psychotherapy with a 3-year-old child: the role of play in the unfolding process.

• Dipartimento di Psicologia dello Sviluppo e della Socializzazione, Università degli Studi di Padova, Padova, Italy

Few studies have investigated the outcomes and process of psychodynamic psychotherapies with children. Among the limited number of studies, some only paid attention to play and verbal production, as they are fundamental aspects in assessing the psychotherapy process. This paper focuses on an empirical investigation of a 3-year, once-a-week psychodynamic psychotherapy carried out with a 3-year-old girl. A process-outcome design was implemented to evaluate play and verbal discourse in in the initial, middle, and final parts of 30 psychotherapy sessions. Repeated measurements of standardized play categories (the Play Category System and the Affect in Play Scale—Preschool version) and verbal discourse (Verbal Production) were analyzed. To increase the clinical validity of the study, data from the assessment phase and vignettes from the sessions were reported to deepen the patient’s picture during the unfolding therapy process. Parent reports before and after the therapy were also included. Empirically measured changes in play and verbal production were fundamental in evaluating the young patient’s psychotherapy process. Verbal production and discourse ability progressively increased and took the place of play, which instead became more symbolic. Developmental issues as well as psychotherapy’s influence on the patient’s change, were discussed in relation to the role of play in enhancing the development of verbal dialog and the expression of the child’s emotions, needs, and desires.

Introduction

Recently, increasing interest has been devoted to the assessment of “operationally defined” markers of the psychodynamic psychotherapy process to alleviate children’s distress ( Delgado, 2008 ), underlining the importance of introducing well-validated and standardized research instruments to study clinical processes ( Midgley and Kennedy, 2011 ; Yanof, 2013 ). The empirical support for psychodynamic psychotherapy with children has been limited as compared with adults ( Abbass et al., 2013 ); few studies have focused on the outcomes and process of psychodynamic psychotherapy with children, and just a small number of them have paid attention to methodological issues ( Weisz and Hawley, 2002 ; Kennedy, 2004 ), including mixed empirical evidence ( Abbass et al., 2013 ).

In psychodynamic psychotherapy for children, the emphasis is not only placed on verbal communication but also on non-verbal communication, by considering the child’s developmental level to facilitate therapeutic relationships throughout the play, drawing and dialog ( Shirk and Karver, 2003 ; Kernberg et al., 2012 ). The development of play is an important milestone in childhood. Play holds a crucial role in providing a safe, caring, protective, confidential, and containing space where children can recreate themselves and their painful experiences through a process of self-cure ( Winnicott, 1942 ; Erikson, 1963 ; Landreth, 2002 ; Bratton et al., 2005 ; Campbell and Knoetze, 2010 ). Pretend play is the best way of expressing thoughts and emotions ( Kernberg et al., 1998 ; Halfon et al., 2016 ) as well as mitigating fears and anxieties ( Harris, 2000 ; Russ, 2004 ; Yanof, 2013 ). It is characterized by the use of fantasy, a level of organization and a standard of comfort ( Russ, 2004 ; Yanof, 2013 ). Fantasy is the process of make-believe, an essential behavior the child engages in during pretend play; organization helps the child to structure pretend play into a story and to utilize cause-and-effect thinking; and comfort is used to assess the ease and pleasure in the engagement in play.

All of these milestones make it easy to understand why play has been considered a preferential way of exploring the inner world of child psychoanalytic therapy since the 1930s, when Melanie Klein and Anna Freud used play techniques to help their young (not fluently speaking) clients to express thoughts, emotions, and feelings. Starting from these beginnings, play has been considered as (a) the primary expressive medium in child psychotherapy to hold meaningful therapeutic value ( Bratton et al., 2005 ; Barish, 2009 ; Campbell and Knoetze, 2010 ), (b) a natural co-constructed means of communication between the child and the therapist, and (c) an useful therapeutic technique to help the child work through different meanings and managing stressful emotions ( Russ, 2004 ; Yanof, 2013 ).

Similar to pretend play, drawing and verbal communication are natural childhood manners of expression, which provides a space where children can feel comfortable ( Brems, 2008 ; Midgley et al., 2009 ; Pace et al., 2015 ; Capella et al., 2016 ). Verbal production, finally, has an important role in assessing the psychological/mentalistic lexicon formed by terms referring to mental states. Its appearance is considered an important indicator of early understanding of mind as well as one’s and others’ internal worlds, and a precursor of subsequent meta-representational capacity ( Bartsch and Wellman, 1995 ; Baumgartner et al., 2000 ; Ornaghi et al., 2010 ). Longitudinal studies suggest that in non-clinical children from the age of 2, the child should be able to use a mentalistic lexicon when referring to perception, complex feelings, and social emotions. At around 3 years, a cognitive psychological lexicon appears concerning internal states related to beliefs, wishes and imagination ( Ornaghi et al., 2010 ).

The principal aim of this paper is to investigate therapeutic change in play, using operationalized and validated measure systems, and to explore its relationship with drawing and dialog in a psycho-dynamically oriented psychotherapy with a 3-year-old girl. Play, drawing and verbal production were fundamental aspects in assessing the therapeutic change. Improvements in psychological complexity and representational skills in terms of symbolic play were expected, given their importance to children of the patient’s age and to the sophistication of verbal skills ( Fein, 1987 ).

The present work was an observational study, corresponding to a level-5 study following the hierarchy of evidence provided by Midgley and Kennedy (2011) ; it provides a detailed discussion of a clinical single case using a process-outcome design. Its aim is to analyze the change during the psychotherapy, using outcome measures to provide a general view on the patient’s functioning through comparison between the assessment phase and the outcome evaluation. In order to provide more robust testing, different types of instruments were used in the assessment and outcome phases, with each one revealing different aspects of specific constructs ( Cheng, 2001 ).

Improvements in play measured during spontaneous play moments and in drawing and dialog within the therapeutic sessions were hypothesized to support more accurate competencies in managing, naming and modulating emotions as well as in talking about “self-inner states.” Moreover, since the positive effect of children’s involvement in non-verbal activities on the verbal expression of inner dialog, measured by verbal production, was expected to progressively increase during therapy and progressively substitute the massive use of play and other activities (e.g., van Nijnatten and van Doorn, 2013 ). A multimethod approach was used to gain incremental clinical validity in understanding the case.

The following paragraph first includes the patient’s – Sarah – referral by her parents and the therapy aims. Then, the instruments and results of play are presented to compare three phases of the treatment. The analysis shifts to measures of play and verbal expression and to therapeutic change during the different stages of the psychotherapy (T1, T2, and T3). Finally, conclusions are drawn to take stock of Sarah’s case to integrate the outcomes with the change during the therapy.

Materials and Methods

Psychotherapy was held in the clinical centre of the University of Padova. Following the service of good practices and the Italian law about privacy and data confidentiality (n°196/03), written and informed parental consent was asked and obtained for video and audio sessions recording, as well as for the participation in the research.

The treatment lasted 3 years and consisted of 55 once-a-week sessions, which were audio-recorded and fully transcribed with the parents’ informed consent. In the present work, 30 sessions were scored and analyzed: 10 from the first phase (T1), 10 from the central phase (T2), and 10 from the last phase (T3) of therapy. Therapy was held by a female therapist in training who received weekly supervision from highly competent clinicians at the University clinical centre. During the assessment and outcome phases, the Affect in Play Scale—Preschool version (APS-P; Russ, 2004 ) was administered to Sarah at the beginning of, about halfway through and at the very end of the therapy, respectively, to assess her cognitive and emotional expression and to observe her level of pretend play.

The Case of Sarah

Sarah was a 3-year-old Italian child who was referred by her parents. Sarah came from an intact family with middle socioeconomic status. Her mother had graduated and worked as an employer; her father was a teacher at an elementary school. They came from intact families and did not report any specific traumatic events in their life.

One year before the present referral, Sarah, at the age of two, was referred by her parents for speech difficulties, oppositional behavior and sleep problems. During that occasion, only parenting support and advice were offered to help the parents better understand and manage Sarah’s difficulties.

One year later, Sarah’s parents re-contacted the centre asking for help because Sarah’s symptoms were back and because they complained about deterioration in some areas. First, the therapist met Sarah’s parents again, without the child, to assess how they perceived her daughter and their functioning toward the child, and the therapist adjourned the child’s anamnestic history. Sarah’s parents were particularly worried about their little daughter. Regarding Sarah’s language impairment, the parents reported Sarah’s decrease in verbal ability (stuttering, changing letters in words and difficulties with naming objects) along with a general regression to baby talk. Sarah’s oppositional behavior had also relapsed, as Sarah often seemed upset and had tantrums. In these situations, Sarah’s parents felt that they were unable to calm down and relax Sarah, and they felt distressed, powerless, and inadequate. Moreover, they reported a regression in several of Sarah’s competencies, concerning feeding (she wanted her mother to feed her), social inhibition (Sarah looked more isolated and less interested in her peers than before) and aspects of separation anxiety (she needed her parents to play with and stay next to her most of the time). A psychodynamic assessment was done using Anna Freud’s developmental lines. In particular, difficulties and regressions were found in many developmental lines at the beginning of the therapy. Following “from dependency to emotional self-reliance and adult object relationships,” Sarah showed a regression to a more dependent phase of life and was unable to stay alone even for few minutes to play or draw, and always asked for her mother’s presence (regression in the line from the Body to the Toy and from Play to Work). At the preschool, she asked for the teacher’s company and showed more difficulties in behaving and playing with other children (regression in the line from Egocentricity to Companionship). She had previously developed the ability to eat using a spoon and a fork, but at the moment of the assessment, she seemed unable to eat alone and was always asking for maternal care and help; in this case, a strong regression in the developmental line “From Suckling to Rational Eating” was found. At the same time, at the age of three, she had begun to wash her face, prefer and choose her clothes and try to dress alone, but at the moment of assessment, her regressive behavior showed she was unable to do anything in autonomy (From Irresponsibility to Responsibility in Body Management).

The therapist observed that the parents were only able to report negative descriptions when talking about their little girl. There was no pleasure or positive affection to share about their daughter. To the therapist, they appeared quite rigid, anxious about the adequacy of Sarah’s behaviors and requests, and to not always be able to understand or support Sarah’s developmental needs or understand their child in connection with her real age and developmental stage. They tended to consider their daughter as a “little adult” whose behaviors were too “childish.” Typically, their interactions with Sarah were about normative conduct: “You are a grown-up girl. Help yourself. Behave yourself. Keep sitting in a good manner.” The interactions surrounding the play were like, “You are playing too much; now, try to draw something nice for your mom.”

During the assessment phase, Sarah showed the impairment her parents had declared, highlighting a state of emotional distress and a sense of emptiness and loneliness. She looked sad, showed poor facial expressions, showed no interest in exploring the room or in playing with toys and did not talk to the therapist. However, she was able to stay alone and was eager to stay with the therapist and to follow her suggestions for interaction. According to the therapist, Sarah showed a disposition (according to her young age) to “use” the therapeutic space and the therapeutic relationship for her developmental issues, and to use the therapist as a “real relational object” to identify and interact with. She absolutely needed her own space (the therapy) to find a new model of relationship in which to express her developmental needs and emotions, without rigid requests of adjustment to be a well-behaved “grown-up girl.”

The therapist thought about what would be the best way to help this family, especially Sarah, and decided to offer a parallel path: to continue working with parents and, at the same time, to offer personal individual treatment to Sarah. The latter was motivated by Sarah’s psychodynamic assessment, which highlighted both Sarah’s indication for psychological support (symptoms and regressions) and quite a stable sense of self to gain better adjustment throughout individual psychoanalytic “developmental help,” as suggested in psychoanalytic training schools for children aged 3 to 5 years old (pre-latency cases). This double therapeutic intervention was accepted by the parents, and they started to have regular meetings twice a month and to support a weekly individual treatment with their child.

The aim of working with Sarah’s parents was to help Sarah’s parents to support their parenting function during Sarah’s therapy. The therapist worked hard to create and improve on her strong working alliance with Sarah’s parents, never making them feel inadequate while at the same time increasing their parenthood abilities to give meaning to Sarah’s behaviors and to keep her needs in mind (also telling them specific vignettes about what Sarah was doing in therapy and connecting the vignettes with Sarah’s behavior they reported at home), to help Sarah reach better adjustment and wellbeing. The therapeutic goals for Sarah focused on behavioral regulation, decreasing inhibition and separation anxiety symptoms as well as modulating her oppositional behavior and increasing her emotional expression. The therapy was also aimed at helping Sarah to acquire relational skills and interest in others to allow her to face new situations more adequately. As in every psychodynamically oriented psychotherapy, the therapeutic relationship played a basic role in the therapy process; play and dialog were used to support the quality of the therapeutic relationships and motivation as well as to reach the therapy goals.

This paper focused on the specificity of the child’s treatment.

The present work includes: (a) a comparison of psychological assessments and therapy outcomes through the Affect in Play Scale—Preschool version, which was administered in line with its standardized procedure (APS-P; Russ, 2004 ); (b) a descriptive analysis about how periods devoted to drawing, playing and dialog changed during the unfolding of the therapy; and (c) a therapeutic change analysis along three therapy sessions, revealed by measures of verbal expression and play and applied on spontaneous play during the sessions. Play was assessed with the adaptations of APS-P and the Bornstein Play Category System at the initial, central, and final phases of selected therapy sessions. Frequencies and type of verbs referring to the state of being, behavior and state of mind were applied as measures of psychological/mentalistic lexicon during each of the 30 sessions, as suggested by Camaioni et al. (1998) .

Tools Description

Affect in Play Scale-Preschool version (APS-P; Russ, 2004 ). The APS-P ( Russ, 2004 ; Kaugars and Russ, 2009 ) is a semi-structured, empirically validated, individually administered 5-min play task that assesses affective and cognitive dimensions of play ( Russ, 2004 ). Standardized instructions and scoring were provided. The child was invited to play with a set of plastic and stuffed toys, including animals (bear, shark) and objects (car, small cups, a “hairy” rubber ball) intended to elicit a range of emotional expressions such as aggression (e.g., a shark). With regard to cognitive scores, organization assesses the quality, complexity, and coherence of the play narrative, with scores ranging from (1) unrelated events, no cause and effect, to (5) integrated plot with a beginning, a middle part and a conclusion. Elaboration refers to the variety and complexity of elements used in the story themes, such as facial expressions, sound effects and characters’ development, from (1) very few details and simple themes with no embellishment, to (5) much embellishment across many dimensions such as details, sound and voice effects and facial expressions. Imagination assesses fantasy and the number of transformations (e.g., using one thing as another) in the play, ranging from (1) no symbolism, no fantasy, to (5) many transformations and fantasy themes. Comfort measures the child’s ability to get involved in the play task and his or her enjoyment of the play, ranging from (1) reticent, distressed, to (5) very involved and enjoying the play. The expression of affects was coded as regarding the Frequency of Affect Expression, which was used during the play session. Affect is scored when an affect theme is expressed in the play. Affect scores can be positive (e.g., nurturance/affection) or negative (e.g., aggression), and they can be summed to form the total affect.

An adaptation of the APS-P using the toys available in the therapy room was used to assess therapeutic change during the therapy by measuring cognitive and affective variables in the spontaneous play in terms of presence and quality (positive or negative) of affect expression as well as the cognitive level of play organization, elaboration, imagination, and comfort. The scores on the APS-P in its regular and adapted use in clinical sessions were calculated by two independent judges – the therapist and a Ph.D. student who were both trained in the APS-P and were blind about which phase the sessions were from. The agreement between the two judges was satisfactory.

An adaptation of the Bornstein Play Category System (PCS; Bornstein and O’Reilly, 1993 ; Bornstein, 2007 ) was used to assess Sarah’s spontaneous play with toys like a dollhouse, a camping tent, and cups, all of which were available in the therapy room. According to this system, play levels are empirically devised to detect the progressive nature of play across the first years of life. Levels 1–4 includes categories of exploratory play, while Levels 5–8 includes categories of symbolic play. A brief description of the levels is reported in Table 1 . The play was coded from videotapes in accordance with the mutually exclusive and exhaustive eight play category levels and a default (no-play) category for each level, and the absolute frequency was calculated. The PCS looked likely to represent a useful instrument in assessing Sarah’s play because Sarah’s level of symbolic play seemed to be scarce at the beginning of therapy, compared to children of her age, and the PCS can give a more detailed evaluation regarding levels of play, from exploratory to symbolic levels. The play categories were assessed in Sarah’s spontaneous play during therapeutic sessions, considering separately the initial, central, and final phases of therapy.

TABLE 1. Trends of play and verbal sophistication from T1 to T3.

Verbal Production

Every language includes very different types of words; of specific interest are words conveying emotions, feelings, wishes, thoughts, and beliefs, all of which are included in what is defined as the psychological lexicon, which is formed by terms referring to mental states. Its appearance in children around 3 years old is considered an important indicator of early understanding of the mind as well as one’s and others’ internal worlds as well as a precursor of the subsequent meta-representational capacity ( Bartsch and Wellman, 1995 ; Baumgartner et al., 2000 ; Ornaghi et al., 2010 ). To empirically identify this developmental progression toward a psychological/mentalistic lexicon, following Camaioni et al. (1998) , verbal production was classified into three categories referring to the acquisition of an increased psychological complexity: (a) state verbs, which are verbal forms that do not refer to mental states such as “there is, there are”; (b) behavior verbs, which are verbal forms that express concrete actions such as eat, walk and read; and (c) mental verbs, which are verbal forms that include all verbal expressions that are more connected with the cognitive and emotional components of thoughts in both positive and negative terms – they not only include feelings and thoughts but also volition states, moral judgments and acknowledgments of abilities. Two blind judges independently scored the test, and the inter-rater reliability was satisfactory.

Data Analysis

The percentages of time devoted to playing, dialog or drawing/other activities were monitored in each session, namely at T1, T2, and T3, to evidence the differing quality of activities that unfolded during the therapeutic session over time. Descriptive statistics and MANOVA for repeated measures were used to analyze the results, with respect with therapeutic change during the three periods, focusing on the quality of spontaneous play in terms of cognitive, affective, and concrete/symbolic modalities of expression. Visual graphics were reported for significant variable changes, specifically assessment and outcome changes as well as the changes within T1, T2, and T3.

Comparison between Assessment and Outcome Scores

According to the APS-P, cognitive expression improved from the assessment to the outcome (Table 1 ; Figure 1 ). Cognitive expression in play was also assessed by comparing Sarah’s results with normative scores of the Italian sample (children between 4 and 5 years; Mazzeschi et al., 2016 ). The Assessment scores were between the 30th and 40th percentiles. The outcome scores increased, reflecting relevant improvements in cognitive functioning. Elaboration and comfort increased through the third quartile (60th and 70th percentiles, respectively), while the organization and imagination scores increased even through the fourth quartile (90th and 95th, respectively), thus reflecting higher scores compared to those of normative sample.

FIGURE 1. Mean, APS-P cognitive and affect scores at assessment and outcome.

Sarah’s APS-P affect scores were also assessed (Table 1 ; Figure 1 ), by comparing Sarah’s results with normative scores of the Italian sample (children between 4 and 5 years; Mazzeschi et al., 2016 ). Sarah’s assessment scores were very low – within the first quartile (between the 10th and 20th percentiles). However, Sarah’s scores increased after therapy, reflecting relevant improvements in her emotional understanding and expression.

Below are examples of Sarah’s verbalizations during the APS-P in T1 and T3:

T1: The animals are doing things. They eat.

T3 : The shark would like to bite the animals. They are very worried. They need help from Daddy.

Total affect increased, going up through the fourth quartile (80th). More specifically, Sarah’s positive affect score was around the median (60th percentile), while her negative affect score was within the fourth quartile (95th percentile), thus reflecting higher scores compared to those of normative sample.

Change in the Measures of Play and Verbal Discourse in the Different Psychotherapy Periods

In order to analyze Sarah’s activities during her therapy sessions, three categories were separately counted in terms of “time” dedicated to: (a) play, in terms of Sarah’s verbal and non-verbal expression during play with toys, using an adaptation of APS-P; (b) dialog, or Sarah’s speech during activities that were different from play; and (c) drawing/other activities, such as book reading and storytelling. Play, dialog and drawing/other activities were measured as percentages regarding the three considered therapeutic periods (T1, T2, and T3). More specifically, drawing/other activities and dialog progressively became more frequent during sessions with Sarah, whereas play decreased (Table 1 ; Figure 2 ).

FIGURE 2. Play, dialogue and drawing/other activities in T1, T2, and T3.

Mean play sophistication, as assessed by the adaptation of the Bornstein Play Category System from Sarah’s play with toys, improved from T1 to T3 (Table 1 ; Figure 3 ). Immature components of play, like functional activities, were replaced by more mature categories, like symbolization sequence and replacement, which started to increase significantly from the beginning to the third period of therapy. For example:

FIGURE 3. Trends of play categories ( Bornstein and O’Reilly, 1993 ), APS-P ( Russ, 2004 ) and verbal expression ( Camaioni et al., 1998 ) in the three times of psychotherapy.

T1: “Here, you are an elephant…he is gray…big…he eats something. I do not know…here, there is nothing to eat. ”

T3: Mom, Dog and his son go for a walk. They go to the swimming pool (she indicates a blue piece of wood)…They have a lot of fun; the little dog was happy. ”

The means and standard deviations of the cognitive variable scores, assessed by the adaptation of APS-P Sarah’s play with toys, are shown in Table 1 . Sarah’s cognitive scores, organization, imagination and feeling of comfort increased significantly from T1 to T3 of the therapy. With respect to affect expression assessed with APS-P during play, the means and standard deviation are presented in Table 1 . At a qualitative level, aggression, happiness, oral and frustration were the most common affective categories in Sarah’s dialog. Total and negative affective expression increased from T1 to T2 and then decreased until the end of treatment (Figure 3 ). In the middle of therapy, due to therapeutic holding, Sarah felt more and more comfortable in expressing negative emotional states, feeling sure about finding acceptance and elaboration. This allowed Sarah to express her negative affect, probably associated with her parents’ failure to provide an adequate holding environment.

See a verbalization in T2:

T2: “This giraffe is very angry…because her friend asks her to run very fast…but she is just a little giraffe…!

The verbs most frequently used in Sarah’s dialog were those referring to behavior ( Camaioni et al., 1998 ), followed by verbs regarding state of mind and state of being (Table 1 ; Figure 3 ). Both behavior and state of mind verbs increased significantly from T1 to T3, reflecting Sarah’s improving capacity to behave concretely and to report her inner mental states.

At the end of the therapy, another developmental evaluation was done using Anna Freud’s developmental lines. Sarah reached normal development in all of the developmental dimensions that were compromised at the beginning of the therapy. The present work analyzed a good treatment outcome in a 3-year-old child, in terms of symbolic play changes. At the beginning of therapy, Sarah was not comfortable with play; thus, during T1, the therapist aimed to make Sarah feel more comfortable with playing in the therapy room. With children who are not able to play, the therapist’s goal is to help them use play as a means of self-expression and as a way of create meaning in the presence of another ( Yanof, 2013 ). T2 represented an important phase in Sarah’s treatment. This is probably due to her acquisition of higher comfort in therapy. Due to the therapy, Sarah’s play progressively improved from exploratory to symbolic play. Moreover, Sarah’s affect expression increased, particularly negative emotions, which did not disappear but strongly decreased in the middle and then re-increased at the very end of the therapy. More important than the quantitative characteristics are the qualitative characteristics of this trend, which seem important from a clinical point of view. Sarah learned to explore and affirm the expression of her negative affect in the therapeutic setting, increasing the “bad feelings” in the middle of the clinical work. Then, she learned to manage and cope with such emotional expressions: the quantity decreased, but more importantly, the quality of the negative affect became more “workable,” and Sarah was more prone to explore and elaborate upon these feelings in her play. Progressively, Sarah expressed aggressive affects through fantasy and cognitive elaboration, which allowed an adequate expression of aggressive emotions in much more of a holding setting like the therapeutic one that, in contrast with her parents, recognized her developmental gains. This was confirmed by Sarah’s assessment/outcome results on the APS-P scores: the percentiles showed that Sarah’s results were not in the normative range for her age at the assessment phase, but at the end of the treatment, the percentiles showed that Sarah had reached the range of normal development in symbolic play. This positive psychotherapy outcome was also confirmed in the analysis of Anna Freud’s developmental line at the end of the therapy: Sarah was less disharmonic that was in line with the developmental stage she was in. The results shed light on further investigation about the process of change.

Play had a core role in this psychotherapy, by showing a link with affective expressions and verbal production. These findings are in line with Russ’s (1993 , 2004 ) theoretical model that proposes play as being strictly connected to both cognitive and affective domains. Through play (and dialog), Sarah learned to express and modulate her feelings when referring to a wider range of emotional patterns. Specifically, her play decreased in frequency, but its quality improved concerning symbolic thoughts, cognitive and affective contents and verbal expression. Lower frequency of play allowed Sarah’s dialog to improve with regards to frequency and quality, such as supporting representation of mental states. Several scholars ( Berk et al., 2006 ) have suggested that make-believe games are forerunners of the important capacity for forms of self-regulation, including reduced aggression, delayed gratification, civility and empathy. The improvement in verbs referring to states of mind reflects this acquisition. Higher levels of negative affect expression, compared to those positive affect, probably reflected Sarah’s feelings of not being initially recognized by her parents, who initially only reported her episodes of tantrum and oppositional behaviors without revealing her positive developmental aspects. From a more qualitative viewpoint, psychotherapy revealed its utility in terms of the decrease in symptoms and the progressive development of cognitive and affective components in Sarah’s functioning. The relationship between Sarah and her parents was very difficult in the first place. Her father and mother were not able to find pleasure in staying with their daughter, and they only reported negative descriptions and faults when talking about their daughter. However, at the end of therapy, Sarah’s mother and father acknowledged Sarah’s improvements, reporting that she showed fewer symptoms when she was at home, such as oppositional behavior.

The present study had some limits, therefore leaving some open questions. Since this is a single case study, the results cannot be generalized. The complexity examined is difficult to represent simply and briefly. The intervening outcomes may have appeared to be stronger if the researcher was more experienced. Finally, it cannot answer a large number of relevant and appropriate research questions ( Hodkinson and Hodkinson, 2001 ), such as – specifically at developmental age – how the change is understandable in terms of psychotherapy’s contribution or the effects of natural developmental issues. Moreover, changes in the drawing activities were not directly measured or evaluated in their changes, but just for their expression in the APS-P and verb categories. More important information could be added in future research with respect with changes in typical drawing dimensions, during the unfolding of the therapy. However, this particular single case with a very little girl could be considered original and ecological because it is grounded in “lived reality” of the therapeutic exchange with a little patient, where communication passed through non-verbal more than verbal communication. Moreover, the particular combination of Sarah’s “developmental help” therapy and the “working with parents” intervention highlighted the importance of creating a working alliance web around the young patient’s suffering. This kind of work increased the effectiveness of the intervention. In this sense, the reduction in the child’s symptoms appeared to be the consequence of the double support to both the parents’ role and the child’s development.

Focusing on play and verbal development, from more concrete to more symbolic, helps us picture the inner world of a patient with a – quite typical and even difficult – immature level of functioning, and understand complex inter-relationships among diagnosis, measures and their clinical application ( Salcuni et al., 2015 ). As Hodkinson and Hodkinson (2001) suggested, a single case study can provide “provisional truths, in a Popperian sense,” until contradictory findings or better theories are developed. Moreover, following a strong empirical approach to change through play and dialog change, this case can be considered useful to highlight the importance of an empirical approach to psychodynamic psychotherapy research with children.

Ethics Statement

We followed the procedure suggested in our Department, in line with the university local ethical committee, asking to both Sarah’s parents for their written informed consent, Sarah is a fictional name, and all information about the child and her parents that could make this family recognizable was modified. The Clinical Service in which the study was conducted, is a recognized research centre of our university (Interdepartmental Laboratories for Research and Applied Psychology, LIRIPAC); all the studies conducted on patients followed the LIRIPAC and Department ethical guideline and procedures, based on the Italian law about privacy and confidentiality (n° 196/03); research practice and ethical procedure were discussed with the Director of the Centre and approved before the research began.

Authors Contributions

SS followed the whole process of the manuscript, supervising it, and writing interpretative conclusions and discussion of the case report; AL supervised method and procedure: moreover, she supervised some years ago the therapist that took care of Sarah; DM wrote the introduction and, together with DDR, performed scoring of the clinical material and the data analysis and the table editing.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Abbass, A., Rabung, S., Leichsenring, F., Refseth, J., and Midgley, N. (2013). Psychodynamic psychotherapy for children and adolescents: a meta-analysis of short-term psychodynamic models. J. Am. Acad. Child Adolesc. Psychiatry 52, 863–875. doi: 10.1016/j.jaac.2013.05.014

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Keywords : psychodynamic psychotherapy, single case study, process-outcome research, child, play, verbal productivity

Citation: Salcuni S, Di Riso D, Mabilia D and Lis A (2017) Psychotherapy with a 3-Year-Old Child: The Role of Play in the Unfolding Process. Front. Psychol. 7:2021. doi: 10.3389/fpsyg.2016.02021

Received: 23 July 2016; Accepted: 13 December 2016; Published: 04 January 2017.

Reviewed by:

Copyright © 2017 Salcuni, Di Riso, Mabilia and Lis. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Silvia Salcuni, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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Criterion Validity: Definition & Examples

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Counselling Case Study: Relationship Problems

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.

Author: Jan McIntyre

Related Case Studies: A Case of Acceptance and Letting Go , A Case of Stress , A Case of Using Logical Consequences

• April 16, 2007
• Case Study , Person-centred , Solution-focused
• Case Studies , Relationship & Families

Comments: 1

Thank you! Very well explained. How to build rapport so that client loosens up.

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