Case Presentation and Case Report Marking Criteria

Please also refer to University guidelines on written material.

RangeAssessment and Formulation Case PresentationAnxiety and Depression Case ReportsExtended Case Report
Distinction
70-100%
Work of exceptional standard reflecting outstanding competence/knowledge of material and critical ability above and beyond those required for a pass mark. As in Assessment and Formulation Case Presentation As in previous Case Reports
Merit
60-69%
Work with a well-defined focus, reflecting a good working competence/knowledge of material and a good level of competence in its critical assessments and beyond those required for a pass mark. As in Assessment and Formulation Case Presentation As in previous Case Reports
Pass
50-59%
Work demonstrating adequate competence/working knowledge of material and evidence of some analysis. Work adheres to the relevant NICE guideline.

A piece of work in this category should include the following (unless a clear rationale for exceptions is given):

Reason for selecting this case, the presenting problems should be clearly identified and described with goals for therapy included.  Where available an appropriate model should be used.  The assessment should include factors relevant to the development and maintenance of the difficulties. Where appropriate the relevant disorder specific assessment and outcome tools should be used as well as IAPT required measures.  A formulation should be present in written narrative from and also a diagram if possible.  This formulation should flow logically from assessment and include precipitating and maintaining factors and where appropriate predisposing/developmental factors.  The intervention plan should be clearly described and flow logically from formulation.

There should be some critical analysis and reflection on the work and the therapeutic alliance.  Throughout the report, a professional and ethical stance should be demonstrated.  References and awareness of relevant literature generally accurate but limited.  Adheres to time limit.

As in Assessment and Formulation Case Presentation and additionally:

The interventions should be clearly described, have clear rationales and flow logically from formulation.  Outcome of the intervention should be described and evaluated. 

 

Adheres to word count.

As in previous Case Reports and additionally:

You will need to clearly identify and reflect on one or two key themes or issues that were apparent or relevant to this case and discuss these with reference to relevant research/literature.

It should demonstrate clear understanding of evidence base practice and provide a critical discussion of the research evidence base in relation to both the work carried out and the specific theme(s) chosen for the reflective analysis.

 

The intervention work must be complete.

Condonable
Fail
40-49%
Limited competence/knowledge of core material and limited critical ability.  Poorly written and presented/structured piece of work.  Rationale and arguments are absent or problematic.  Inappropriate application of theory to practice.  Severe departures from APA referencing. As in Assessment and Formulation Case Presentation As in previous Case Reports
Fail
0-39

Lacking in basic competence/knowledge of core material and absence or major flaws in critical analysis. 
Unethical practice, breaches in confidentiality**
Severe departures from APA referencing.

As in Assessment and Formulation Case Presentation As in previous Case Reports

Case Reports

Trainees submit three case reports over the year on three different clinical cases. Trainees also present one case as a case presentation during the year which must also be on a different case.

One Anxiety and One Depression Case Report (4,000 words each)

Aims

The purpose of these case reports is to demonstrate your grasp of the application of cognitive theory to clinical practice.

Extended Case Report (7,000 words)

This can be of a client with either anxiety or depression.  The client used for the extended case report can be any of the 8 closely- or non-closely supervised cases (either depression or anxiety) which have not been used for any other case report or the summative case presentation previously.  For the Extended Case Report, the intervention work must be complete.

Aims

The overall aims of the extended case report are for you to demonstrate your grasp of the application of cognitive theory to clinical practice by demonstrating an understanding of evidence-based practice and providing a critical discussion of the relevant research/literature evidence to this case.

You will be required to reflect on one or two key themes or issues that were apparent or relevant to this case and discuss these with reference to relevant research/literature. You may wish to include transcript of sessions with this client to illustrate your points and provide material for reflection. The area chosen may relate to any area of CBT and clinical work. Examples might include cultural or diversity issues, different cognitive-behavioural models, process issues, issues relating to the therapeutic alliance, contextual or systemic factors, co-morbidity.

 

NB A good case does not necessarily mean one with a good outcome

We require you to demonstrate not just your application of CBT theory to clinical practice but also your reflections and learning related to this piece of clinical work and your understanding of evidence-base practice.

NB In all case reports material presented must reflect accurately the assessment and interventions carried out with the relevant client.  If misrepresentations come to light the case report will automatically fail.  Case studies submitted should be signed by workplace supervisors to verify that the written piece accurately represents the clinical work carried out.

Anxiety and Depression (4,000 word) Case Report Guidelines

Trainees will be assessed on the following dimensions:

*Assessment
Should include:
  • Reason for referral and for seeking treatment at this point.
  • Description of the presenting problem(s)/symptoms, diagnosis and co-morbidity including use of DSM 5 criteria and full consideration of differential diagnosis (all possible diagnoses which were considered/ruled out for this client based on their symptoms, experiences and measures)
  • Relevant background/personal information, including development of the problem, predisposing, precipitating, perpetuating, protective factors and current social circumstances.
  • Risk assessment.
  • Identified treatment goals for therapy (focus on SMART goals).
  • Issues relating to engagement and the therapeutic alliance.
  • Issues of diversity and difference (or similarity) between client and therapist and the impact on the therapeutic relationship.
  • Use of the relevant model to guide assessment, formulation and intervention (if it is not used reasons for this should be given). For depression cases, the Beck model should be used.
  • A cognitive behavioural assessment of the presenting problem(s), including a description of identified situations/triggers, cognitions, emotions, physical symptoms and behaviours.
  • Socialisation to the model and suitability for CBT.
  • Scores on IAPT service outcome and assessment measures.
  • Relevant disorder specific assessment questionnaires (if not a reason should be given).
*Conceptualisation / Formulation
  • Where a particular model has been used to guide formulation this should be referenced and accurately described including an accurate description of the theory underpinning the model. 
  • There should be a narrative description of the case conceptualisation within the text, and clarified, where possible, by a diagrammatic representation of the conceptualisation.
  • The formulation should link and fully explain the maintenance factors of the client's presenting problem(s) and where relevant the development of the problem.
  • Ensure that the arrows on any diagrammatic formulations make sense, flow accurately and reflect both the theory and actual experience of the client.
  • The formulation should relate to the client’s goals and flow from the assessment.
  • Ensure a focus on collaboration with explicit client contribution.
*Intervention
  • Interventions (carried out or planned) should directly relate to and flow from the client’s identified goals and the case conceptualisation, to demonstrate how treatment was idiosyncratic
  • A minimum of 5 sessions should have been completed, including treatment/interventions
  • Clear rationales for the interventions carried out should be given based on the theory, goals and case conceptualisation.
  • Enough detail should be given in the text so that it is clear what was done, but a blow-by-blow account of each session is not required.
  • The relapse prevention plan should be included.
  • Include reference to relevant NICE guideline(s).
  • Identify any difficulties experienced and relate back to the case conceptualisation where possible.
*Critical evaluation/outcome
  • You need to evaluate the interventions as applied and the outcome of the case.
  • You need to demonstrate evaluation over the course of therapy (not just at the end) so that you can demonstrate that you are on track with the intervention.
  • Present IAPT service outcomes for the client (ideally also through depiction of a graph) and critically discuss scores, considering also fluctuations in scores and why these may have occurred
  • You should re-administer and report on all measures that were used at assessment (if not a reason should be given).
  • Outcomes should be clearly related back to the identified goals of therapy.
  • You should critically evaluate the work and outcome to date; e.g. why you think the changes have occurred?  Or if no changes have occurred why this may be?  Where possible relate this back to the case conceptualisation and/or the theory/model.
  • Where an intervention has not been completed you need to present the current outcome in relation to the identified goals. 
  • Refer back to relevant NICE guideline(s), where possible.
*Link of theory to practice

This is covered to some extent in previous areas. 
Throughout the report you need to:

  • Relate the clinical work carried out to relevant cognitive-behavioural theory and relevant models throughout.
  • Use theory/research/literature to guide your assessment, formulation, intervention plan and critical evaluation.
  • Refer to and make use of the relevant literature to show how this was guiding your thinking about this case.
Self reflectivity
Throughout the case report you should demonstrate a reflective approach to the work you carried out and the use of methods/tools to aid this process. For example we would expect you to provide a rationale for the work carried out that draws on your ability to reflect on theory/therapeutic alliance/socio/political/organisational/professional and ethical factors. Reflection may involve demonstrating an awareness of the way that your own assumptions/beliefs might impact on the process and outcome of therapy with due consideration of how this may shape and develop your practice in the future. You may find it helpful to provide an outline of any tools or mechanisms that you used in order to aid this process (e.g. supervision discussion, protected preparation time for therapy & supervision sessions, a reflective model, thought records, listening to session recordings, SP/SR etc.). 
Awareness of professional issues (including confidentiality)
Your work should demonstrate good professional awareness, e.g. awareness of:
  • Issues of risk including how risks were managed and reviewed
  • Ethical issues
  • Power dynamics
  • Issues of diversity and difference and the impact on the therapeutic relationship.
  • **Client confidentiality; anonymised biographical data must be used throughout the report and there should be no identifiable information in relation to the client or service i.e. you need to change any names and identifying information and make it clear that this has been done
Structure and style

Marks will be awarded for a well-structured case report.  The case report should read well and flow in a logical manner.  Be mindful of your use of language both the use of colloquialisms and jargon. Trainees should refer to themselves as 'the author' rather than 'I' within academic writing.

Where appropriate you may use diagrams, tables and bullet points. These should be used to aid clarity of information in the main text.  Key information needs to be in the main body of the text and any information in tables/diagrams needs to be at least summarised within the main text. Key information such as each of the '5 Ps', risk, differential diagnosis, narrative description of the formulation, interventions, critical evaluation, and the theory underpinning the work all needs to be described within the text.

If used, subheadings should relate to subsequent material presented and help to structure your case report. If used, appendices and footnotes should be used appropriately and not to help with word count.  Appendices should be clearly referred to, labelled and follow the reference section.

A possible structure could be based on the marking criteria e.g.: Outline/introduction to the client and the case report, reason for referral, presenting problem(s), assessment, formulation, intervention plan and critical evaluation.  Theory to practice links, self reflectivity and professional issues could be covered throughout in the previous sections or as separate sections.

References
References should conform to APA (7th Edition) both in text and at the end of your case report (see University guidance). Please check references in terms of accuracy and consistency and ensure that all citations in the text are referred to in the reference section. Minor errors with referencing will not impact on the overall mark, however disregard for APA referencing, or severe departures from APA, may impact the overall mark.
Spelling, grammar, typographical errors and presentation
Work should be double spaced and page-numbered.  Work should be comprehensible and so please check for typographical, grammatical and spelling errors.  Where possible ask someone else to proof read your case report before submitting. If you need support in this area please use the study skills department.  
Word count
Word count excludes: case report title, tables, figures, headings for tables/figures, the reference list, and appendices. All other words are counted. Work exceeding this limit will not be marked and will not receive credit.

* Indicates a key area; insufficient information in any of these areas or failure on more than one of these areas is likely to result in an overall fail.

**Confidentiality Breaches in Case Reports:

  1. In Case Reports there should be no identifiable information in relation to the Client or Service.
  2. A minor breach in Case Reports, where confidentiality/anonymisation has occurred and been acknowledged by the author, but then a minor mistake(s) gets picked up will be returned to the author for correction. The Trainee will have 48 hours (excluding weekends) to reply and correct the errors, otherwise it will be marked as a fail. The Trainee will be notified via their University email account by the Programme Administrator. If the breach occurs during a vacation period, then they will also receive an alert to their work and personal email addresses (where these have been provided) asking them to urgently check their University accounts.
  3. When major breaches are present or anonymisation has not occurred and/or been made explicit, this will be an automatic fail and the Trainee would need to resubmit a second submission correcting the error (and making any other changes if there are any other resubmission criteria).

 

Download Forms

Please refer to the Download Forms page.

 

Extended (7,000 word) Case Report Guidelines

Trainees will be assessed on the following dimensions:

*Assessment
Should include:
  • Reason for referral and for seeking treatment at this point.
  • Description of the presenting problem(s)/symptoms, diagnosis and co-morbidity including use of DSM 5 criteria and full consideration of differential diagnosis (all possible diagnoses which were considered/ruled out for this client based on their symptoms, experiences and measures)
  • Relevant background/personal information, including development of the problem, predisposing, precipitating, perpetuating, protective factors and current social circumstances.
  • Risk assessment.
  • Identified treatment goals for therapy (focus on SMART goals).
  • Issues relating to engagement and the therapeutic alliance.
  • Issues of diversity and difference (or similarity) between client and therapist and the impact on the therapeutic relationship.
  • Use of the relevant model to guide assessment, formulation and intervention (if it is not used reasons for this should be given). For depression cases, the Beck model should be used.
  • A cognitive behavioural assessment of the presenting problem(s), including a description of identified situations/triggers, cognitions, emotions, physical symptoms and behaviours.
  • Socialisation to the model and suitability for CBT.
  • Scores on IAPT service outcome and assessment measures.
  • Relevant disorder specific assessment questionnaires (if not a reason should be given).
*Conceptualisation / Formulation
  • Where a particular model has been used to guide formulation this should be referenced and accurately described including an accurate description of the theory underpinning the model.
  • There should be a narrative description of the case conceptualisation within the text, and clarified, where possible, by a diagrammatic representation of the conceptualisation.
  • The formulation should link and fully explain the maintenance factors of the client's presenting problem(s) and where relevant the development of the problem.
  • Ensure that the arrows on any diagrammatic formulations make sense, flow accurately and reflect both the theory and actual experience of the client.
  • The formulation should relate to the client’s goals and flow from the assessment.
  • Ensure a focus on collaboration with explicit client contribution.
*Intervention
  • Interventions carried out should directly relate to and flow from the client’s identified goals and the case conceptualisation to demonstrate how treatment was idiosyncratic.
  • The main body of the intervention must be completed (the client may still be seen for follow-up or relapse prevention). The relapse prevention plan should be included.
  • Clear rationales for the interventions carried out should be given based on the theory, goals and case conceptualisation.
  • Enough detail should be given in the text so that it is clear what was done, but a blow-by-blow account of each session is not required.
  • Include reference to relevant NICE guideline(s).
  • Identify any difficulties experienced and relate back to the case conceptualisation where possible.
*Critical evaluation/outcome
  • You need to evaluate the interventions as applied and the outcome of the case.
  • You need to demonstrate evaluation over the course of therapy (not just at the end) so that you can demonstrate that you were on track with the intervention.
  • Present IAPT service outcomes for the client (ideally also through depiction of a graph) and critically discuss scores, considering also fluctuations in scores and why these may have occurred
  • You should re-administer and report on all measures that were used at assessment (if not a reason should be given).
  • Outcomes should be clearly related back to the identified goals of therapy.
  • You should critically evaluate the outcome; e.g. why you think the changes have occurred?  Or if no changes have occurred why this may be?  Where possible relate this back to the case conceptualisation and/or the theory/model. 
  • Refer back to relevant NICE guideline(s), where possible.
*Link of theory to practice
This is covered to some extent in previous areas. 
Throughout the report you need to:
  • Relate the clinical work carried out to relevant cognitive-behavioural theory and relevant models throughout.
  • Use theory/research/literature to guide your assessment, formulation, intervention plan and critical evaluation.
  • Refer to and make use of the relevant literature to show how this was guiding your thinking about this case.
*Critical appraisal of themes
You need to clearly identify one or two key themes or issues that were relevant to this case (see suggestions above).
You should critically appraise:
  • The literature around these themes
  • The work/intervention with reference to this literature.
 You should take an objective and critical stance to the work carried out.
Self reflectivity
Throughout the case report you should demonstrate a reflective approach to the work you carried out and the use of methods/tools to aid this process (e.g. the use of supervision), specifically in relation to your chosen theme(s). For example we would expect you to provide a rationale for the work carried out that draws on your ability to reflect on theory/therapeutic alliance/socio/political/organisational/professional and ethical factors. Reflection may involve demonstrating an awareness of the way that your own assumptions/beliefs might impact on the process and outcome of therapy with due consideration of how this may shape and develop your practice in the future. You may find it helpful to provide an outline of any tools or mechanisms that you used in order to aid this process (e.g. supervision discussion, protected preparation time for therapy & supervision sessions, reflective models, thought records, listening to session recordings, SP/SR etc.). You may wish to include a transcript of sessions with this client to illustrate your points and provide material for reflection.
Awareness of professional issues (including confidentiality)
Your work should demonstrate good professional awareness, e.g. awareness of:
  • Issues of risk including how risks were managed and reviewed
  • Ethical issues
  • Power dynamics
  • Issues of diversity and difference and its impact on the therapeutic relationship.
  • **Client confidentiality - anonymised biographical data must be used throughout the report and there should be no identifiable information in relation to the client or service i.e. you need to change any names and identifying information and make it clear that this has been done.
Structure and style

Marks will be awarded for a well-structured case report.  The case report should read well and flow in a logical manner.  Be mindful of your use of language both the use of colloquialisms and jargon. Trainees should refer to themselves as 'the author' rather than 'I' within academic writing. 

Where appropriate you may use diagrams, tables and bullet points. These should be used to aid clarity of information in the main text.  Key information needs to be in the main body of the text and any information in tables/diagrams needs to be at least summarised within the main text. Key information such as each of the '5 Ps', risk, differential diagnosis, narrative description of the formulation, interventions, critical evaluation, the theory underpinning the work and critical appraisal of theme/s all needs to be described within the text.

If used, subheadings should relate to subsequent material presented and help to structure your case report. If used, appendices and footnotes should be used appropriately and not to help with word count.  Appendices should be clearly referred to and labelled and come after references.

A possible structure could be based on the marking criteria e.g.: Outline/introduction to the client, the case report and key themes that will be discussed; reason for referral; presenting problem(s); assessment; formulation; intervention plan; and critical evaluation and reflective analysis.  Theory to practice links, critical appraisal of theme/s, self reflectivity and professional issues could be covered throughout in the previous sections or as separate sections.  

References
References should conform to APA (7th Edition) both in text and at the end of your case report (see University guidance). Please check references in terms of accuracy and consistency and ensure that all citations in the text are referred to in the reference section. Minor errors with referencing will not impact on the overall mark, however disregard for APA referencing, or severe departures from APA, may impact the overall mark.
Spelling, grammar, typographical errors and presentation
Work should be double spaced and page-numbered.  Work should be comprehensible and so please check for typographical, grammatical and spelling errors.  Where possible ask someone else to proof read your case report before submitting. If you need support in this area please use the study skills department.  
Word count 

Word count excludes: case report title, tables, figures, headings for tables/figures, the reference list, and appendices. All other words are counted. Work exceeding this limit will not be marked and will not receive credit.

* Indicates a key area; insufficient information in any of these areas or failure on more than one of these areas is likely to result in an overall fail.

**Confidentiality Breaches in Case Reports:

  1. In Case Reports there should be no identifiable information in relation to the Client or Service.
  2. A minor breach in Case Reports, where confidentiality/anonymisation has occurred and been acknowledged by the author, but then a minor mistake(s) gets picked up will be returned to the author for correction. The Trainee will have 48 hours (excluding weekends) to reply and correct the errors, otherwise it will be marked as a fail. The Trainee will be notified via their University email account by the Programme Administrator. If the breach occurs during a vacation period, then they will also receive an alert to their work and personal email addresses (where these have been provided) asking them to urgently check their University accounts.
  3. When major breaches are present or anonymisation has not occurred and/or been made explicit, this will be an automatic fail and the Trainee would need to resubmit a second submission correcting the error (and making any other changes if there are any other resubmission criteria).

 

Download Forms

Please refer to the Download Forms page.