Clinical Psychology and Psychotherapy Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
Psychological services sit inside healthcare systems, so a therapist's decisions rarely stay inside the consulting room. Referrals arrive with medical histories, handovers move risk between shifts and teams, and waiting lists force choices about who is seen first. The five cases below follow the same working questions: what the patient needs now, what the clinical evidence actually shows, how colleagues share that picture, and which local protocols set the limits. Read each one for the decisions, the trade-offs, and the points where a process could have been designed differently.
Case Study 1
Escalating symptoms in a long-running therapy caseload
Larkmoor Community Psychological Services, an outpatient service offering assessment and talking therapies to adults across three neighborhood clinics.
The situation
Miriam had attended outpatient sessions for four months with low mood and sleep problems that had eased steadily. In the fourth week of a new phase her clinician Dev noticed that she repeatedly lost the thread of sentences, asked him to repeat questions, and described headaches that woke her at night. She also said she had stopped driving because she felt unsteady. Dev recorded these changes, treated them as a possible anxiety flare, and kept the planned schedule. Two weeks later her partner called after she missed an appointment, reporting more confusion at home. Review of the notes showed no referral had been made.
The challenge
The team had to decide whether this was a change in psychological presentation that could be managed within the therapy plan, or a sign of a medical cause needing prompt assessment outside the service. Dev's notes suggested both possibilities. The service has no capacity to investigate physical causes, so the decision depended on how quickly the team recognized changing signs and routed them. The local protocol required same-day supervisory review and medical referral within two working days when new cognitive or physical signs appeared.
Analysis
The patient's needs had shifted from the agreed goals of therapy to a safety question. Miriam could no longer reliably follow a session, was not driving, and had a partner who was noticing changes the clinical notes did not capture. Clinical evidence in this case was not a test result but a pattern across sessions: a change in language, a new somatic complaint, and a functional loss. A pattern like that calls for a wider differential than a flare of the presenting condition, and the clinician's role is to name it, record it with dates, and bring in the people who can assess it.
Coordination broke down where information existed but did not travel. Dev had the observations, the partner had the wider picture, and the supervisor had not read the notes before the missed appointment. Local protocol placed same-day review on the clinician whenever new cognitive or physical signs appeared, so the gap was partly about how the rule was understood. Services that manage this well keep a short list of triggers that override the usual plan, and they place that list in the record and on the duty roster so cover staff are not left to interpret it alone.
Actions taken
- Convene a same-day discussion with the supervising psychologist, using the trigger checklist to confirm whether the changes fall outside the expected pattern for the presenting problem.
- Contact the primary care team and request a medical review, sending a dated summary of session observations, the partner's report, and the missed appointment.
- Ask the client's consent to share information with the referrer and her partner, documenting what she agrees to share and what she declines.
- Set a named contact and a follow-up date in the record, and add the trigger list to the duty roster so cover staff see the same escalation rule.
Results
Miriam was seen by her primary care team within the week, and the medical review identified a cause that needed separate follow-up outside the therapy service. The supervising psychologist and Dev agreed to continue sessions at a reduced frequency while that plan was clarified. Review of the case showed the referral went out nine working days after the first change was noted, because the note was filed as routine. The intake template now carries a flagged field for new physical or cognitive symptoms, and an audit of the following quarter found the flag used in most relevant sessions.
Questions for discussion
- Describe the point at which Dev's observations should have triggered supervisory review, and identify what information he would have needed to recognize that threshold.
- Assess whether the two-day protocol window is realistic for a service without on-site medical staff, and propose how the team would document an exception.
- Explain how the client's consent and her partner's involvement should be balanced when the partner is the person who raised the concern.
Case Study 2
A missed handover from hospital ward to community team
Brackenridge Liaison Psychology Team, a hospital-based service providing psychological assessment and short-term therapy to patients on general wards and to their community teams.
The situation
A patient named Jorge had been seen by the liaison psychologist, Ines, during a three-day medical admission, where he disclosed thoughts of self-harm that were judged manageable with a written safety plan. Ines wrote a summary and planned a follow-up call to the community team. Discharge happened on a Friday afternoon, and the ward handover to the discharge nurse listed the safety plan but not the pending call. The community team's duty clinician, Priya, received an automatic referral with the discharge letter but no direct message. Over the weekend the call did not happen, and nobody on the community team read the letter as urgent until Tuesday.
The challenge
The gap was not in any single document. The safety plan existed, the letter was sent, and both teams were acting in good faith. The risk sat in the space between them: the discharge nurse had no field for pending actions, and the community duty process did not separate urgent referrals from routine correspondence. The team had to decide what had actually been handed over, and whether Jorge's risk had been transferred or merely copied.
Analysis
Jorge's needs at discharge were specific and time-limited. He had disclosed distress that the liaison assessment judged manageable, but that judgment depended on follow-up contact within a short window, and the safety plan assumed a human check-in would happen. Clinical evidence in this case lived in Ines's summary, which was thorough, yet a summary records what was found and not what must happen next week. Teams grounded in Clinical Psychology and Psychotherapy usually start by asking which information must travel with the patient and which needs a named person and a date.
The applicable standard was the service's transfer of care rule, which asks the sending clinician to state pending actions, owners, and deadlines. Ines's letter met most of that standard. The gap was that the ward's discharge template had no field for pending actions, so the nurse reasonably passed on what the template could hold. Coordination depends on a shared language for urgency. When the community team could not tell a routine letter from a time-bound safety check, the weekend became the failure point. A short verbal handover, or a direct message to the named duty clinician, would have closed the gap.
- Assessment Liaison psychologist records risk and the agreed safety steps.
- Summary Letter states findings but may omit dated follow-up actions.
- Ward handover Template carries the plan but has no field for pending calls.
- Duty review Community team reads routine letters in order, so urgency can be lost.
Actions taken
- Add a required field to the discharge template for pending actions, each with a named owner, a deadline, and a note on what happens if the action is missed.
- Require a direct, same-day message to the named community duty clinician for any follow-up contact due within seventy-two hours of discharge, in addition to the automatic letter.
- Introduce a weekend cover check in which the duty clinician reviews discharges flagged as safety-relevant and confirms receipt by phone before the shift ends.
- Ask the liaison service to audit handovers for two months against the four-part standard, reporting the proportion with all parts complete to the quality group.
Results
The discharge template was revised within the month, and the first audit of thirty handovers found that twenty-two had all four parts complete, against a baseline of fourteen. Two of the remaining eight had pending actions with no owner, which the quality group treated as the priority for the next cycle. The weekend check identified one discharge in its first month where the community team had not read the letter, and that patient was contacted the same afternoon. The team did not claim the risk was eliminated, since the audit showed phone confirmation depended on who was on shift.
Questions for discussion
- Trace the handover path for Jorge step by step and name the point where the urgency of the follow-up call could have been recorded in a form the receiving team would act on.
- Compare a direct clinician-to-clinician message with an automated letter as the primary channel for transferring time-bound actions, and state which risks each one leaves open.
- Explain how the weekend check should be staffed so that it does not depend on one individual's familiarity with the case.
Case Study 3
Choosing who waits when therapy capacity runs short
Tanglewood Psychological Therapies Hub, a regional service providing short-term talking therapies and assessment to adults referred from primary care.
The situation
Tanglewood received 1,240 referrals over six months, against a clinical capacity of roughly 62 new assessments and 340 therapy sessions a month. By the time the operations manager, Samuel, pulled the figures together, 380 people were waiting and the median wait had doubled since the previous review. The team had nine clinicians on paper, but two were on long-term leave and one worked part-time on a supported return, leaving 6.5 full-time equivalent posts. Referrals were triaged by date of receipt, so a person with a recent deterioration could wait as long as someone whose need had been stable for months. Hana, the clinical lead, reported two cases last month where risk rose while people were still waiting.
The challenge
Three options were on the table. The first was a stricter triage that moved people by clinical need rather than arrival date. The second was a scheduled group format for lower-intensity needs, which would free individual slots. The third was to close the list to new referrals for a period. Each option protected some patients and disadvantaged others, and the team had to keep the decision anchored to need, not to convenience.
Analysis
Patient need was hard to track here because intake data went stale. The referral form captured a presenting problem and a self-rated score, and these were rarely updated while a person waited. A triage rule built on a single intake reading will rank stable people too high and deteriorating people too low. The service's own audit found that roughly one in five people whose risk had changed while waiting had no review recorded in the previous month. Good practice treats the waiting period as clinical time, using brief contact points to refresh need before any allocation decision is made.
The prioritization protocol allowed clinical lead discretion for rising risk but did not say who must be told when a change was recorded. The triage meeting happened once a week and the operations manager set the agenda from the waiting list, so clinical concerns raised between meetings reached the table late. Weighing triage against group scheduling and list closure needed a shared view of demand that the operations and clinical teams did not yet have. A short panel of the clinical lead, the operations manager and a senior clinician could make allocation decisions in one place, with a written record of who was moved, held, and why.
Actions taken
- Re-score every person on the waiting list against a short need review by telephone, recording the date and the reviewer for each change.
- Replace date-of-receipt triage with a weekly panel that ranks people by current need, using agreed criteria written into the prioritization protocol.
- Pilot a group format for lower-intensity needs for one quarter, with a clinician present for every group and a stepping-up route back to individual care.
- Set a monitoring line on median wait and on the number of people whose risk rose while waiting, and review both at each monthly governance meeting.
Results
The re-scoring exercise moved 46 people up the list and 31 down, and the first panel reviewed 58 cases. Median wait for new assessments fell, although the list stayed above 350, which the team called a capacity problem rather than a triage success. The group format took 40 places and led to two people stepping back to individual care within a month, which the clinical lead counted as the scheme working. Monitoring showed the share of people whose risk rose while waiting fell from one in five to about one in twelve, though that depended on weekly review volume.
Questions for discussion
- Estimate how many of the 46 people moved up the list would have been missed under date-of-receipt triage, and describe what evidence would confirm that estimate.
- Assess the risk that a group format for lower-intensity needs could mask deterioration in people who are misclassified at intake, and propose a check that catches this.
- Describe how the allocation panel should record decisions to hold someone on the list, so that the record protects both the person and the service's accountability.
Case Study 4
Inconsistent outcomes across three neighborhood therapy sites
Quillhaven Adult Talking Therapies, a service with three neighborhood sites offering short-term psychological therapy and routine outcome monitoring.
The situation
Quillhaven's three sites began from the same referral pathway and the same outcome measure, yet by the end of the review period their results differed. Across 2,180 people who started therapy, the proportion completing the routine questionnaire at the final session ranged from under half at one site to nearly three-quarters at another. Average sessions attended also varied, and the site with the highest attrition had the lowest share of people reporting reliable improvement. Mireille, the service manager, asked for a review, and Olu, the data analyst, prepared anonymized site-level indicators for the team to examine.
The challenge
The obvious explanation was a difference in patient mix, but the sites had similar referral profiles on the intake data. The team had to separate real differences in outcome from differences in how sessions were recorded, how measures were collected, and how people were followed up after they stopped attending. Without that separation, any improvement plan would target the wrong process, and a poor result at one site could be read as a clinical failing when it was a recording gap.
Analysis
Patient needs cannot be read from a completion rate alone. People who stop attending early may be those whose needs were met quickly, those who found the format unsuitable, or those whose circumstances changed. The indicators did not distinguish these groups, so the first step was to look at the pattern of endings. Clinical evidence about outcome depends on the measure behind it, and a questionnaire that is skipped by the people who most need a review gives a flattering picture of the site. A useful review asks what each site's patients were experiencing when they left, and whether the outcome data captured that experience at all.
The service's routine outcome protocol required a questionnaire at intake, at the midpoint, and at the final session, with a follow-up request sent to anyone who stopped attending without a discharge conversation. Coordination depended on each site's clinicians recording endings consistently and on administrators sending the follow-up request. The north site completed the final measure in the room, while the other two sites sent it by message, which lowered the response rate for people who had already left. Improvement work usually starts by naming who owns each step, because a protocol that is clear on paper can still fail three different ways across three sites.
Actions taken
- Pull the final-measure completion and dropout data by site and by stage of ending, so the team can see whether gaps cluster in early endings or in late ones.
- Run a short case-note audit of twenty endings per site, checking whether a discharge conversation and a follow-up request were both recorded and by whom.
- Agree one completion route for the final questionnaire across all three sites, sent in the same way and at the same point in the ending process, with a named administrator.
- Run a three-month monitored cycle with monthly reviews of all five indicators, stopping early if completion falls at any site, and reporting each review to the quality group.
Results
After the first monitored cycle, final-measure completion rose at two sites, and the Mill site moved from under half to just over two-thirds of endings. Follow-up requests were sent within the agreed window for most people who stopped attending, although the team recorded that a small number had gone to outdated contact details. Reliable improvement rates were still uneven, which the group took as evidence that the outcome measure had been comparing groups with different completion patterns. The team agreed to report completion beside outcome in every summary, so no site's result could be read without its response rate.
Questions for discussion
- Explain why a completion rate that rises after a process change may still hide differences in who is responding, and describe how the team would check for that.
- Compare the strengths of a case-note audit with those of direct conversations with clinicians at each site when identifying causes of inconsistent endings.
- Describe the criteria the quality group should use to decide whether the cycle should continue, be adapted, or be stopped at the end of the monitoring period.
Case Study 5
A partner asks for information about a client's care
Ashgrove Psychological Care Unit, a clinic providing adult therapy and consultation to primary care and community teams under a written confidentiality protocol.
The situation
Teodor had been attending weekly sessions for five months at Ashgrove, and his written consent covered sharing summaries with his general practitioner and nothing else. In the seventh week of a recent block, his partner, Lena, telephoned the clinic. She asked whether he was attending, whether he had said anything about harming himself, and whether the clinic could tell her what to watch for at home. Ruth, his clinician, had noted in the last session that he described hopelessness and had declined to make a safety plan with his partner involved. The duty manager, Kofi, took the call and recorded the request without giving any information.
The challenge
Three duties pulled in different directions. The clinic owed Teodor confidentiality and respect for the consent he had given, and it owed Lena a response that did not breach either. It also owed attention to any risk that the clinician judged to be rising. The team had to decide whether the call changed the level of risk, whether it justified a disclosure beyond the agreed scope, and what the clinic could say to Lena now without revealing anything Teodor had not agreed to share.
Analysis
Teodor's needs were clear in one respect: he had capacity, was attending voluntarily, and had limited what could be shared. The clinical evidence was less settled. Hopelessness recorded in a session is significant, but it is not the same as an assessed level of risk, and the clinic had no current risk assessment after the most recent session. A family member's question can be a sign of concern that deserves a response, or it can be an attempt to gather information that the person would not wish to be given. The clinician's notes should separate what was observed, what Lena reported, and what was judged.
Ashgrove's confidentiality and information-sharing protocol sets the default: information stays within the agreed scope unless the client consents, a legal or statutory requirement applies, or there is a serious risk to life that cannot be managed another way. Consent in this case was specific, which limits what the clinic can do without a new conversation with Teodor. The protocol also requires that any decision to share beyond consent be made by the senior clinician with the duty manager, recorded with reasons, and reviewed the same day. Coordination here means Ruth returns to Teodor first and that any escalation is shared, not left to one person on a busy day.
- 1Confirm consent scopeCheck the signed agreement and what Teodor agreed to share with whom.
- 2Return to the clientSpeak with Teodor first about the call and about what Lena asked.
- 3Senior clinician risk reviewRecord observed risk, reported concerns, and judgment separately, with reasons.
- 4Decide and documentAgree any disclosure with the duty manager and record the scope and review time.
- 5Respond to LenaExplain emergency routes and what the clinic can and cannot confirm.
Actions taken
- Hold the call note in the record and check Teodor's signed consent, confirming which people and organizations he agreed could receive information and in what form.
- Arrange a conversation with Teodor, led by Ruth, to tell him that his partner called, what she asked, and what the clinic can and cannot share, before any decision is made.
- Have Ruth and Kofi complete a documented risk review the same day, recording observations, Lena's concerns, and the reasons for any decision to share beyond consent.
- Write a reply to Lena that gives no client information, explains the clinic's position on confidentiality, and sets out how to reach emergency services and the service out of hours.
Results
Ruth met Teodor the next day. He agreed that Lena could be told the clinic had received her call and given support information, but declined any further disclosure. The same-day risk review found no change that required sharing beyond consent, and it set a follow-up contact within two days with a clear route back to the duty manager. Lena received a written reply that explained the clinic's position and provided emergency contact details. The case went to the monthly governance meeting, where the team agreed to add a family contact prompt to the intake consent form.
Questions for discussion
- Identify the points in Teodor's case where the clinic's duty to confidentiality and its duty to respond to risk could conflict, and describe how the record should show that each was weighed.
- Evaluate whether the intake consent form should include a family contact section, and what risks such a section would create for clients who do not want relatives involved.
- Compare the value of a written reply with a telephone reply when responding to a family member who has asked for information the clinic cannot give.
Learning Resources
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