The case for change

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The case for change
by Mary Aspinwall

I was taught this particular way of writing up cases by Jeremy Sherr, who was in turn taught it by someone else whose name escapes me. I've told quite a few people about it and those that have changed over to this method are all delighted with it.

The Case for change
It is quite hard to give up the way you've always done things, but in this instance I found the benefits made it well worth the effort of letting go of my old habits. Like all good ideas it is simple. In an ideal case-taking many of us would like to have a verbatim record of literally everything the client says so that the vital clues hidden in
their language are not lost. On the other hand this means you end up with a very unwieldy document at the end, which you have to scan repeatedly to pick out the cherries. So to mix my food-obsessed metaphors how can you have your cake and eat it?

Layout
Divide the paper into four sections.
The largest of these should be on the right-hand side (half
the width of the page).
In the middle put a very narrow column.
To the left two columns of the same width.
Starting from the left head these columns:
Schema! Phenomena! Miscellaneous! Text
Leave about a fifth of the page free at the bottom.
Head this part Rubrics to the left and Comments to the
right. Click here to have a look at an example.

Printing
To save time you can run off some pre-printed grids on a computer by using any spreadsheet progamme. This has the added advantage of faint lines to stop your writing sliding off in all directions. Print on both sides of the paper - save a tree! If you need a lot, it is probably best to have a ream or two of paper printed. It should cost about 15 pounds for double-sided and the price goes down the more reams you get. Don't print a ream until you have tried out your version and made sure it suits you.

Getting started.
Your client comes in and you start by taking their name, address, telephone, date of birth, etc. on some form of cover sheet that is also pre-printed. This is prime time to listen out for simple language. The client is usually relaxed because these questions are straight-forward and they will answer them semi-automatically, often with little asides. Don't miss any of these. Jot them down on the next page in the fat "text column. Even at this stage avoid any question that can be answered "yes or "no . You will get more information if you stick to WHquestions. (Who?! What?! When? ! Why?! Where?! How?) To give an example: instead of asking "Are you married? (which may anyway turn out to be an insensitive question) you could ask after noting the address "...and who lives there with you? Make a note of the other occupants names, ages, relationship with the client. This will be useful later as the client will feel able to explain situations more fluently, if they know you are already familiar with the dramatis personae and you will not need to interrupt their flow to ask who is who.

First impressions
As soon as possible note down your first impressions of the client. In the narrow column (Misc.) write "obs and then make a note of anything that strikes you under the Text heading. Since this is not their verbatim speech put it clearly in parentheses. You may not want the client to see you doing this, so use a clipboard to write on and keep it up a little. You might also choose to write a discreet short-hand note to remind yourself of something (e.g. "nails instead of "she bites her nails or "hair instead of "bald patches ).

Be open, create a space to be filled
Begin with a very open request: "Start wherever you like...
If they have come with a shopping list of symptoms you will use the two columns to the left if there is nothing but the symptoms. For instance:
"My feet feel as if they are burning when I'm in bed at night .
Could be written up in this short form:
Schema Phenomena Misc. Text
Feet burning SAl <in bed < at night However, if the client then goes on to say "It's killing me . This needs to be written in full:
Schema Phenomena Misc. Text It's killing me

Mark this simple language with an exclamation mark in the miscellaneous column so that you can find it fast. If the client then repeats this expression at any time you can underline the phrase. In this way no underlines means they said it once, one underline means twice, two means thrice and so on. After they have gone you will notice anything that they have said repeatedly. You may then want to make an addition to the left hand columns:
Schema Phenomena Misc. Text Mind del. killed/murdered ! It's killing me

Allow the client to talk uninterruptedly for as long as possible. Find out where their time, energy and attention is. Don't interrupt. When they run out of steam you will have a chance to go back over anything that was not clear in the notes you have thus far. Leave some space and mark the section you need to check out with an asterisk, so that you can easily go back and fill in the gaps.

Always distinguish between what was volunteered, unprompted, by the client and what came out as the result of a prompt from you by putting a question mark in the misc. column next to their answer. This will be helpful once the client has gone. For example if at the end of an anecdote you felt the need to ask : "How did that make you feel? , then you need to record that prompt and the response like this:
Schema Phenomena Misc. Text
? I don't know, I suppose I felt a bit taken for granted As it does not have the same value as:
Schema Phenomena Misc. Text
I'm just so sick of being taken for granted (two underlines)
This is why it is important to have the exact words and nuances recorded. The short-form for both of these would be indistinguishable:
Schema Phenomena Misc. Text Mind del, appreciated is not
but it would be an unsafe rubric to take in the first (prompted) case. Click here to have a look at an example.

Family History
Have a separate family history sheet, laid out like a family tree to note down medical history and details of relationships. Once again this is usually a prime time for gathering simple language as the questions are perceived as routine and so are often answered without any editing on the part of the client. After taking the family history ask a good open question, such as: "...and how do you all aet on? Make verbatim notes on the next sheet.
Time line
If the life story or medical history is complex make notes on a printed time-line Start at the top with the client's mother's pregnancy and the client's birth and put their current age at the bottom of the page. Divide up the intervening space, not uniformly but, according to how eventful a particular time was. This will be helpful in making connections and finding possible aetiologies. Once again, if the language becomes especially rich at any point, change over to the main pages and use the text column.
Click here to have a look at an example.

When I case-take, I case-take
There is a lovely story of a Zen master whose pupil asked what he should do to gain enlightenment, to which the Zen master replied: tat and sleep . The student protested that he already did this. To which the Master replied: "Yes, but when I eat, I eat and when I sleep, I sleep.
If someone is in the flow of their story, just try to catch every word and ignore the first three columns totally. You will easily be able to go back and add to them once the client has left. In any case it is essential to stay completely focussed on them rather than to jump on to the next stage in your own mind and start coming up with rtibrics or, worse still, remedies. If you are not truly there at that moment how can you hear what is being said?

Loose ends
Sometimes allowing the client free rein to talk about whatever is most significant to them can cause the homeopath anxiety. There is the nagging thought: "What if I miss something that is vital to the case? This is unlikely to happen, but it is always helpful to allow a period at the end where you guide your client in a visualisation that starts at the top of their heads and goes to the tips of their toes and they can add any forgotten details.
In addition you may even like to give yourself a little crib sheet to check off at the end. This could include Digestion, Respiration, Urination, Perspiration, Temperature, Sleep, Dreams, Appetite, Thirst and so on.

Case analysis
Once the client has left, the ideal thing would be to allow a short period immediately after for a read through, whilst the details are still fresh in your mind. At this stage you can add any thoughts, hunches, etc. in parentheses. After that my personal preference is to set it aside for a while and return to it fresh. Look at the miscellaneous column for your observations and any ! marks. Decide whether you want to make any of these into rubrics.
Write the possible rubrics at the bottom of the relevant pages. Check to see if any of the general or physical symptoms in any way echo the simple language used. These are often the most pertinent to the case.
Under the comments section write down any thoughts you have regarding prognosis, maintaining causes, obstacles to cure, etc.

At this stage you will have lots of different rubric possibilities and commentary scattered over the bottoms of several pages. Consolidate your final selection(s) and thoughts on to one page.
If you use a computer repertorisation programme, go into the Options File and make sure you have selected "cross- references!. This means that when you go to a rubric all similar rubrics will be listed and you can re-evaluate and decide if any of them might describe the symptom more accurately. You may decide to combine two rubrics that you consider equally valid choices into one rubric. If a suitable rubric can't be found you could use Reference Works to search the Materia Medica and create the rubric you need, then export that to the Repertory programme and include it in the analysis.

What next?
Then just find the simillimum and make yourself a nice cuppa (tee hee).

Rewards
This method of laying out the case makes analysis much clearer and stops important little details getting lost. Recently I had a case where a woman said: "If I didn't watch what I eat all the time, I would literally not be able to get through that door!!. Since she was a very trim size 12 and the door is a standard size, I marked this with an!

When I came to choose the rubrics there was a similar comment on another page also highlighted so I decided it was significant and repertorised on it. I really think that using my old case-taking method, I would have either not written the comments at all or they would have got lost in the midst of so much detail. Yet, perhaps the real joy of this method of case-taking is when someone nngs you with an acute and you quickly grab their notes and run your eye down the left hand column and both the details and the whole essence of the case come flooding back to you. You will instantly know, for example, if the acute is, in fact, a return of an old symptom. Follow-ups too are a breeze. You have the case in front of you and once the client has been given all the time they need to say what is upper-most on their minds, you can run through their initial symptoms with ease. It is also easy to spot any significant shifts in their use of language. I bless the day I learnt how to case-take this way and I hope you find it of as much use...

© Mary Aspinwall