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The treatment case report

On this page:
- When to use a 'treatment case report'
- Elements of the treatment case report
- Submitting the treatment case report

When to use a 'treatment case report'

The 'treatment case report'  is only relevant for 1-year Master students.

These guidelines are intended  for those students who will not be undertaking a psychodiagnostics internship (no BAPD-certificate) , but are interning in institutions that primarily offer treatment.  The treatment case report has a structure that is quite similar to the diagostic case report. However, the treatment case reports cannot be used to receive the BAPD and/or LOGO GZ-certificate.

During the clinical internship, the student selects three treatment processes with three different clients and works towards completing case reports for them as described in this document. This document constitutes a guideline for case reports describing the care needs assessment and treatment processes of specific clients.

The three case reports must cover as broad a range as possible in terms of the care needs assessment and treatment processes used. At the time of submission the case studies may be no more than two years old. For more information about the requirements relating to the diversity of the case studies in terms of care needs assessments and treatments, see section 3.3 in particular.

Maastricht University uses these reports to test students’ knowledge and skills in the field of general psychodiagnostics. No distinction is made between psychodiagnostics in a non- clinical setting and a clinical setting. For this reason, the same model is used for case study reports in both settings, and the components of the case study report are denoted by terms that apply in non-clinical and clinical settings alike. However, the explanations of the various components do differentiate between the terminology used in each setting.

The case report relating to care needs assessment and treatment must be written in such a way that it is clear why certain assessments and treatment options were chosen. This must be substantiated with scientific evidence. The report must also state how the treatment(s) relate to the care needs assessment, whether the treatment was helpful and what qualifications must be made in light of scientific-professional considerations.

The components of the report reflect the steps taken when working through the care needs assessment and/or therapy process. The report must demonstrate that the student has used information sources that are appropriate to the exercise of responsible practice (whether clinical or non-clinical). These sources of information comprise extant theoretical and empirical material in the relevant research area, the set of research tools available for assessment in the relevant domain, an understanding of the error and bias inherent in subjective, unsubstantiated assessment and lines of reasoning, and the professional experiential knowledge that has been documented in guidelines, protocols and case studies. Considerations, choices and decisions should be explained with reference to the literature used. The report should also discuss the oral and written reports provided to clients and/or the principal and how these proceeded. In view of the requirements described above, these reports differ from the way real case reports are normally drawn up in practice. The case report should comprise no more than ten pages, including the raw scores and references.

Elements of the treatment study report

The case study report is made up of the following elements:
Client data
Reason for referral
Intake (i.e. how the care needs assessment resulted from the diagnostic process)
Treatment plan
Observations and impressions
Examination of the effects of the treatment (pre- and post-treatment measurements)
Summary and comprehensive picture
Conclusions relating to the effects of the treatment and recommendation
Signatures of student and supervisor at the internship institution

Below is a short description of the required content of each component.

Client data
All personal data relevant to a case study, such as age, gender, family situation, employment/education, research setting and the referrer must be stated. If the diagnosis has been requested by an organisation, the client is an employee or potential employee, and the organisation, generally represented by a manager, director or HR adviser, is the referrer and principal. In this situation, the client is also a representative of the organisation/principal, so it is important to be mindful of the potential sensitivity of the data. Explicitly state that the data are being anonymised. Do not use the names of institutions and/or organisations (including the organisation requesting the assessment, if applicable). Remove or disguise information such as the names of family members, identifiable research data, birthdates, professions, place names, etc.

Reason for referral or request for diagnosis
In a few sentences, indicate why the client referred themselves or was referred for diagnostics.

Provide a summary, in a few sentences, of those details which were already known prior to commencement of the treatment process, drawing on referral letters, file content which has been forwarded, the intake meeting (whether this was by telephone or in person), and/or any diagnostic assessment completed. Briefly summarise the information that the care needs assessment has been based on (such as the perceived symptoms (i.e. the client’s subjective perspective of their current symptoms/problems), the development of the symptoms/problems over time, and relevant case history information or the view of the principal). The intake meeting is concluded by formulating a concrete care needs assessment for treatment relating to the client's symptoms and/or the views of the client/principal/psychodiagnostician.

Treatment plan
Ensure there is sufficient diversity in the types of treatments across the three cases. Reference must be made to scientific literature, published case study reports or experiential knowledge to evidence the efficacy of these treatments.
Clearly indicate what the treatment(s) will consist of (e.g. frequency, content (i.e. whether the treatment is aimed at providing support, providing insight or bringing about change), whether it will be conducted one-on-one or in a group setting, who will be supervising the treatment etc.).
This section will also state what type of outcome measures the treatment(s) is/are expected to have an impact on. This hypothesis, or these hypotheses, must be substantiated from scientific literature, published case study reports or experiential knowledge.

Observations and impressions
Under ‘impressions’, describe your first impressions and observations regarding the client’s presentation during the intake and/or treatment (such as appearance, eye contact and demeanour, description of symptoms and the feelings evoked in the examiner, and the client’s responses to unintended interruptions to the examination context). Under ‘observations’, provide targeted observations relating to the way the client responded to the examination or test instructions and the manner in which the client carried out the assignments. Pay attention to not only the client’s cognitive functioning, but also their affective and emotional reactions and – in performance tasks – their sensory and motor functioning. Only mention observations that are both noteworthy and relevant to addressing the diagnostic issue. It should be noted that both ‘positive’ and ‘negative’ features can be relevant to observations and impressions; the former category concerns phenomena whose presence is readily observable, while the latter concerns phenomena that are notable for their absence (for example, in the case of a person who self-reports as having serious memory issues, an unexpectedly strong ability to remember details from previous examinations).
When interpreting the results, the extent to which observations and impressions either agree with or contradict the other findings of the examination must always be systematically evaluated. Wherever specific and/or more structured observation methods are used to test (or help test) specific hypotheses, they should be treated as part of the examination method and described in the ‘Examination of the effects of the treatment’ section (3.2.6).

Examination of the effects of the treatment (pre- and post-treatment measurements)
State how the hypotheses or questions relating to the effectiveness of the treatment will be explored. Use tools such as symptom questionnaires (level of suffering, coping and quality of life), tests, projective techniques, structured observations and interviews, possibly in combination with file analysis.

The tools can vary in psychometric quality and relevance to the different domains. Use different methods for each case study, and use as great a variety of methods as possible across the three case studies. State the criteria that must be met in order to arrive at a conclusion concerning the effects of the treatment (i.e. the assessment criteria) for each hypothesis or research question. Discuss the considerations and choices underlying the decision to use (or not use) specific measurement. This is particularly relevant in cases where instruments which may have limited psychometric benefits are used, or if the client's background (for example a different cultural background) diverges significantly from that for which the tool was originally intended or standardised.

The student must be mindful of the fact that much of the research into the psychometric qualities of psychological tests is based on tests which have been conducted only once (for example in the context of psychodiagnostics). To conduct and interpret these tests in a treatment setting, it must be demonstrated that they are appropriate for this context (for example if they are to be conducted multiple times, with interpretation focusing on the differences between the different test scores).

State the findings (pre- and post-treatment measurement(s)) for each research tool. Indicate the extent to which the observations will be taken into consideration when interpreting the findings. Indicate to what degree the findings meet the assessment criteria that were formulated at the outset to determine whether or not the treatment has been successful. State, and substantiate, which hypotheses relating to the treatment effects will be accepted, rejected or will require further research.

Summary and comprehensive picture
Start the summary by stating who has referred the client for treatment, followed by a brief summary of the findings from the intake meeting and the treatment results. Then formulate a comprehensive picture in which observations and results are related to each other. Present this picture as an overarching interpretational framework, and refer to the academic sources used to substantiate the way different ideas have been integrated into the whole. Where possible, these explanations will be substantiated by references to empirical research, theoretical insights, documented practical knowledge and the student's own practical experience. Avoid unwarranted coherence by also mentioning anomalous data which does not fit into the picture.

Conclusions relating to effects of the treatment and recommendation
Based on the summary and comprehensive picture, conclusions are formulated and recommendations made for follow-up interventions or possibly for further psychodiagnostic investigation.

In this section, you are expected to provide insight into how you applied the diagnostic process in this case study and to identify your key learning moments. In other words, you are asked to take a bird’s eye/overarching view of the case study. This includes reflecting on your personal learning process and performance during the different stages of the care needs assessment and treatment process. Which parts or stages of the process went well? What did you find difficult and why? What insights did you come to? This could include professional and personal limitations and/or boundaries that you ran up against, for example in terms of expertise, working with the client system, intercultural aspects, dealing with and learning from feedback in supervision, the selection of research tools and interpreting the results, justifying or explaining the chosen methods, etc.

In this section, you are expected to provide insight into how you dealt with ethical issues in this case study and to identify your key learning moments. Refer to different aspects of professional ethics and relate them to this case study, for example professional and scientific responsibility, equal treatment and openness towards the client, being clear about your role as a psychologist, respecting the client’s right to privacy and confidentiality, and being mindful of the limitations of your own expertise and experience. To what extent did you act with respect for the client’s autonomy, responsibility and equality, and how is this evidenced?

Signature of the student and the supervisor at the internship institution
You and the supervisor at the internship institution must declare that the case reports pertain to real cases that were investigated by the student independently (though under supervision) and at the requisite level. You use the cover sheet (fillable PDF-form) for this.

You must always state which test results are needed to assess the interpretation process (i.e. standardised scores (deciles, percentiles, T-scores, IQs, confidence intervals, etc.)) and specify which standards have been used (if they deviate from the guidelines). This can be done in either an appendix or the report itself, as long as the interpretations and conclusions are transparent and verifiable for the reader. Use the APA guidelines when citing sources. A bibliography must be included as an appendix to the report.

Explanation of the different stages in the treatment process

Needless to say, the threatment process begins with registration and ends with the outcomes that have been achieved in terms of the effectiveness of the treatment. Between these beginning and end points, a process takes place in which, from the treating clinician's perspective, there are frequent switches between deliberation and action. The deliberation element concerns the formulation of hypotheses, the interpretation of data, the choice of appropriate interventions, and the integration of any ongoing observations. The action element consists of actually carrying out the activities that relate to the decisions made as a result of the deliberation process. The general structure of the diagnostic process can be found in the section delineating the scope of the report, which states the reason the person has been referred or has self-referred for treatment (the start of the treatment process), followed by the categories 'intake meeting', 'treatment plan', 'treatment' (with accompanying observations and impressions), 'summary and comprehensive picture', 'conclusions and recommendation' and reflection on this process. These categories represent the main stages in the process. If necessary, key stages can be repeated and the process, including the final conclusions,revisited based on the updated results and treatment(s). The partial stages making up these main stages have already been implicitly covered in the description of the elements of the case study report presented above.

The stages of the treatment process can also be arranged by type within the basic methodological figure of the empirical cycle, consisting of the stages of observation, induction, deduction, testing and evaluation. The referral and intake meeting provide the starting material (observation) required to develop the examination of treatment effect, with these first steps resulting in the choice of a theoretical and empirical framework (induction), based on which testable hypotheses are formulated (deduction). By carrying out the examination, hypotheses can be tested (testing), and the resulting findings are summarised and integrated within the context of the diagnostic issues (evaluation). It should be noted here that the diagnostic process cannot be approached as a by-the-book application of scientific research. Rather, it is about working in the spirit of the empirical cycle. Expectations should be stated clearly, tested empirically and the findings critically evaluated in a process that is anchored as firmly as possible in the behavioural sciences and in the generic supporting disciplines developed in this domain such as research methodology, statistics, psychometrics and decision theory.

Submitting the treatment case report

Fill in this signed cover sheet (fillable PDF-form; one cover sheet per three case reports). Send the cover sheet to the FPN supervisor and cc to fdp-masterthese@maastrichtuniversity.nl.

Each report must be no more than 7000 words (including raw scores and normtables, and works cited, but excluding the cover page; for the report itself a maximum of 5000 words is acceptable). Each case report must preferably be written in Dutch, or where this is not possible, in English. The report must be written preferably in 10pt Arial or Helvetica or a similar 10pt sans serif typeface. One-and-a-half line spacing should be used, with 2.5 cm margins on each side. The pages must be numbered. Each report must be emailed (in PDF or Word) to the FPN supervisor. (paragraph updated 22-03-2022)

Last modified: Tue, 19/07/2022 - 10:40

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