ABSTRACT
A clinical case report is a clinical document that describes the results of the diagnostic assessment of a client and specifies a plan of treatment consistent with the presenting problem and the case conceptualization. An integrative clinical case report is a clinical case report that is internally consistent, formulation-based, cogent, and coherent. Preparing a report that is internally consistent, formulation-based, cogent, and coherent is an essential competency that trainees and therapists can find considerably challenging. The clinical case report is not simply a document containing the facts of the case or a summary of all the data collected in the diagnostic assessment interview. In my view, it is more like a legal brief, which makes the case for a specific diagnosis, a specific case conceptualization, and a specific treatment plan. Rather than being a nontheoretical description of a client’s life and concerns, the clinical case report should be a theoretically informed explanation and tailored treatment prescription. Furthermore, the report should be internally consistent, meaning that the diagnostic formulation and DSM diagnoses should directly reflect the presenting problem and be directly addressed in the treatment goals and focus specified in the treatment formulation. Finally, a clinical case report should be a compelling portrait of the client: present (presenting problem, etc.), past (developmental history, etc.), and future ( treatment plan, etc.). The portrait description should be sufficiently compelling and
detailed that other clinicians could pick the client out of a line-up. For all practical purposes, such a report reflects the professional’s capacity to “think like a therapist.”
