Identify and briefly describe your client (e.g., identifying characteristics such as age, race, ethnicity, gender, sexual orientation, marital status, health, employment, and/or school status, and living arrangements; if a group, such as task group or school group, briefly identify each group member using these categories of information). Include how your client came to the attention of your agency or its social work unit. Identify the reason for the referral (such as presenting problems). Discuss the degree to which the client or client system was mandated for services or voluntarily chose to receive services.
Presenting Problems and Problem-for-Work
Discuss the presenting problems the client or clients brought and then describe one problem-for-work for your client(s). (Note: there may be several presenting problems on which you can work; summarize the situation and problems generally, and then, focus on one for the purpose of this analysis. Remember, a problem-for-work may not be the presenting problem (Levine, 2014), but, the problem-for-work is an underlying issue that you both agree on) (Levine, 2014). Include an analysis of the problem as the client sees it, as significant others view it, and as other service providers see it (Miley, et al., 2017, pp. 240-241, Adding Viewpoints). Be as non-judgmental as possible for this section.
Medical History/Family History/Educational Background
Include a brief summary of relevant historical information, depending on your particular client group and how much you know about the client. This section is past tense – other sections are present and future tense.
Include observations you make regarding the client’s presentation to you of the problem(s) – this includes only what you see, hear or intuitively experience yourself (i.e., observations about your own reactions and the impact on the client) (Bisman, 2014, pp. 104-105; Miley, et al., 2017, p. 241-243). Observations are NOT opinions, but what you see, hear, or intuitively experience or observe about yourself that contributed to the selection of the problem-for-work and development of your case theory. For example, “every time I asked Maria about her relationship with her mother, she would change the subject, raising a bit of concern in me. She said she isn’t ready to address that. She did openly discuss how unhappy she was in her job, which led me to think that this may be where we can start.” Here, change theory can be used to inform the case theory – she is in the pre-contemplation phase in terms of recognizing she has a problem with her mother. A discussion of tuning-in with the client (Shulman, 2009) may be applicable here.
Provide at least 2 plausible hypotheses for the cause (etiology) and/or maintenance of the problem-for-work. Make sure that your hypotheses reflects a person-in-environment perspective and you identify and incorporate at least two theories that inform your hypotheses such as social constructionism, humanistic, behavioral, cognitive behavioral, psychodynamic, attachment, etc. Your application of the theories MUST be explicit (name your theories and describe the principles and how they say about your client – they why). You must include relevant references from the readings here. Remember, case theory can change as more information is obtained and/or you have more experience with the client. But it is important to be able to articulate your emerging hypotheses to yourself, your client, and colleagues as you will be continuously testing out your hypotheses or case theory through the assessment and intervention processes.
Address in your case theory section how racism, poverty, sexism, homophobia, transphobia, or any other type of structural/societal oppression (disability, immigrant, etc.) play a role in the client’s presenting problem or problems. To what degree is the relationship impacted by structural and societal oppression? This is where you can incorporate some of the theory on constructionism (Wood & Tully, 2006) into your case theory.