案例督导书写要求

案例督导书写要求

案例报告书写指引（详见下文）

Recommendations for writing a Case Report

(Total time for presentation: 30 minutes)

1. A short note on the patient’s gender, age, education background, marriage situation and vocation （一般情况）患者的性别、年龄、教育背景、婚姻情况和居住地。

2. Reason for referral: which problems was mentioned. Psychiatric diagnosis: who made it and when? Do the patient use medication? If the patient use medication which name/names they are ? and how the patient experienced the psychiatric trentment process? If the patient has had a psychotherapy how did he or she experienced ?

首诊或前来咨询的原因：主要问题是什么？精神科的诊断如何？由谁在何时做的诊断？患者是否接受过药物治疗？是什么药物？患者对精神科治疗经历的体验是怎样的？如果患者接受过心理治疗，她/他的体验是怎样的？

3. A short note on your first impression of your patient

简单描述对患者的第一印象

4. Which problems and complaints did the patient mention in the first interview?. Howdid the patient present her/his problems and suffering?

第一次访谈中患者的主诉是什么？患者是怎样显现她/他的问题和痛苦的？

5. Early life background: important others and important experiences, especially the trauma expericences. Just give a clear–cut summary; you don't need to describe in to much detail.

早期生活经历：重要他人和重要的体验，特别是创伤的经历。尽可能简明扼要的描述，不必使用太过细节的陈述

1-5 = 10 minutes以上第1至第5部分用五分钟报告

6.Therapeutic setting: contract, sessions, frequency, fee

治疗设置：契约的约定，疗程、频率、费用。

7. Therapeutic process: A short description of the process so far

治疗过程：简短描述治疗过程。

8.Describe shortly how you see the patient's problems:how did they develop, how is it now. What problems do you think the patient is struggling with? What difficulties/questions you expericed in the past sessions?

简短描述你如何看待病人的问题：病人的问题是怎么发展而来的？目前是怎样的？你考虑病人内心的挣扎是什么？在过去的治疗之中，你体验到的困难及问题是什么？

6-8 = 5 minutes

从第6至第8报告五分钟

9 Dialogue:Try to give detailed reports, also with dialogues, from one or two sessions. This is important and gives us material for detailed and meaningful

discussions of therapeutic work (method and technique) in supervision. 对话：给一段誊录的治疗对话

9 = 15 minutes