1

Case Summary

S.S is 48 years old female. The clinical supervisor referred the client to the trainee clinical

psychologists for psychological assessment and management. The client came with the presenting

complaints of aggressive behavior, irritability, and feeling of loneliness, sleep disturbance, depressed

mood, loss of interest in work and daily activities and loss of control. Assessment was done on both

the informal and formal levels. For informal assessment, clinical interview, mental status

examination was done, and subjective rating of symptoms was taken, and for the purpose of formal

assessment Young Mania Rating Scale (YMRS) was administered. For the purpose of management

Rapport building, Psycho education, Activity schedule, Progressive muscle relaxation, Deep

breathing, Cognitive restructuring, Behavioral activation was done with the client. The outcome of

client’s management suggests that client had improvement in her mood, and has started thinking

interest in daily activities.

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Bio data

Name S. S

Age 48 years

Gender Female

Siblings 6 (two sisters, four brothers)

Birth order 5th

Religion Islam

Marital status Divorced

Informant Client

Reason for referral

The client was brought by her brother to the Haji Abdul Qayyum Trust hospital, Sahiwal with

the presenting complaints of aggressive behavior, irritability, and feeling of loneliness, sleep

disturbance, depressed mood, loss of interest in work and daily activities and loss of control. The

clinical supervisor referred the client to the trainee clinical psychologists for psychological

assessment and management.

Presenting complaints

Table.1

Presenting Complaints of the Client as Reported by the Client himself

Duration Presenting complaints

‫ سال‬8 ‫بہت غصہ آتاہ‬
‫ سال‬9 ‫چئن ی‬
‫ھوت ےھ‬ ‫ئ‬ ‫ےب‬
‫ سال‬9 ‫ی‬
‫ہوجات ھو‬ ‫اداس‬
‫ سال‬8 ‫نہئ ملتا بزاری ی‬
‫ھوت ہ‬ ‫سکون ئ‬
‫ے‬
ؑ
‫ سال‬8 ‫دلچسن لن کو دل نہں کرتا‬
‫ی‬ ‫مئ‬
‫کیس رسگریم ں‬
‫ سال‬8 ‫ایک جگہ بہٹن ےس سکون ئ‬
‫نہئ ملتا‬
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History of present illness

According to the client her problem was start after the death of her father. She was much

closer to her father. She shares each and every thing with her father. Her father was died when the

client was eighteen years old. Client’s mother was the second wife of her father. Client parent live

happily married life. Her parent’s gives loves, care and emotional support to her siblings and herself.

When she was started her matriculation she was diagnosis TB. Because of her disease she left study

and takes treatment for this disease. Her father looks her and gives emotional support, love and care.

When the client was recovered from her disease her father left her alone in the world. She

was very depressed after the death of her father. She started to live in dark room. Most of the time

she feels sad, worried and feel loneliness. Her father death was proves a tragic incident in client’s

life. She never can sit with peace; she had feels irritability and discomfort. She shows anger over the

small things. When these entire problem can affect client’s normal life and her routine then her

mother take appointment from psychiatrist in Faisalabad. In mental hospital of Faisalabad her

treatment was started. She consult best psychiatrist. Her psychiatrist prescribes medicines and starts

therapy for her presenting complaints. She used these medicines for six months. She feels better after

taking medicines and therapies. After this her psychiatrist went to other city and during this time she

consulted other psychiatrist. Her new psychiatrist advised her to stop using these medicines and

suggested her to takes only therapies. After sometimes client again faces problematic symptoms. Her

mood was elevated and depressed. She again started to live alone. After sometimes her first

psychiatrist was come to hospital. She again consulted with her psychiatrist, her psychiatrist rule out

her condition and her symptoms. When she discuss to her psychiatrist about all her problems and the

reason of stop using prescribed medicines, her psychiatrist was show anger why she stop these

medicines and again prescribed her medicines. So she again uses these medicines.

After few years when the client’s was twenty nine years old she got married. She does not

share with her husband that she had consulted psychiatrist and took medicines for her treatment
 4

because her psychiatrist advise her not share anything with her husband about her disorder and

treatment. Her husband was not sincere with her and also does not earn money. Her in-laws were

very greedy people. She was not happy with her husband. Often there was a quarrel between her and

her husband. Both of them were not happy with their married life. After six months her husband

divorced her. After her divorced she was depressed and her symptoms were started again. She

decided that she did not marry again in her life and then she started to teach Quran to children.

Suddenly her mother had died and again she felt alone. Her brothers were advising her to get

marry again therefore she again got married. Her second husband was very cooperative, loving and

caring towards her. Her husband gave her lots of love and care. On the other hand her treatment was

also continued but she often forgot to takes medicines therefore she showed depressed mood,

irritability and loss of interest in daily activity. Her married life was affected because of her rude

behavior towards her husband. Most of the times, she lay on bed and did not show interest in social,

daily and married life also did not showed interest in her husband. After two years her husband gave

her divorced. She was very sad after her divorce because she loved her husband. Her second divorce

also played a role to maintain her problems. Because of her mental condition her brother admitted

her in hospital. There the client took medicines and psychotherapies timely. She wanted to recover

from her problems and again start her normal life. She set goals for her life and wants to achieve

these goals.

Background information

Family history The client belonged to a middle class family. The client lived in joint family

with her parents, siblings and her uncle family. Her mother was the second wife of her father. Her

parent’s marital relationships were good and satisfied. Her father ran small business. Her mother was

a house wife.

The client had one sister and four brothers in which two brothers and sister was her step

siblings. She had only two brothers by blood. She was only daughter of her mother. The client’s
 5

elder brother was married and has three children. Her younger brother was married and has children.

She had good relationships with her brother. She was not much satisfied and good relation with her

step sister and brothers. The client was much closed to her parents and her siblings. She was the

pampered child of her parents. Her brother’s showed loves and care towards her. Her father loved her

very much and she was closed to her father and shares everything to her father. The client’s father

had passed away when she was eighteen years old. After the death of her father she was very

depressed. She felt loneliness. After the death of her father she became closed to her mother and

started sharing her issues with her mother. After the death of her father her mother gave her

emotional support. Before the death of her father the home environment of her house was satisfied

and healthy but after the death of her father the home environment of her house was not healthy and

much satisfied for her. Her mother had passed away when the client was 25 years old. After the death

of her mother her brothers took care of her. Her relationships with their brothers were satisfied and

her brother gave her care and attention.

Home environment The client reported that overall her home environment was good. Before

the death of her father they have faced no financial issues and her father was the only bread earner of

her house. After the death of her father they face some financial issues but after sometime her brother

took the responsibility. They lived in joint family therefore sometime some issues were raised in

family but they may resolve easily. The client was a loving daughter of her parents therefore all of

them showed love and care towards her. According to client the overall general home environment of

her house was healthy and satisfied.

History of physical and psychiatric illness in family According to the client there were no

any physical and psychiatrist history in her family. Her father had passed away because of heart

attack.

Personal history She reported to have normal birth with no complications. The client did not

report any injuries, trauma or any unusual event during her childhood. She acknowledged having no
 6

history of any neurological problems with her developmental milestones. She achieved her

milestones in appropriate age range. There was no history of behavioral problems like bed wetting,

temper tantrum; social withdrawal in early childhood. She had normal development of speech and

other milestones. She had a disease of TB when she was in metric. But she was recovered from her

disease.

Educational history The client belong to Faisalabad, therefore she started her education

from her home town. She started her education when she was four years old. She completed her

education from private school. She was not a brilliant student. She was an average student. She had

no interest in her studies. Her teacher was not satisfied with her academic performance. She was

good in extracurricular activities. When she had passed her middle and took admission in

matriculation, she was suffered with TB and because of this disease she left her study. When she

recovered from her disease she did not again started her education. She was fed up from her study

and took more interest in religious education. After some years she started to teach Quran Pak to

small children. She felt peace after teaching the children Quran Pak.

Occupational history The client never took interest in any occupation for sake of money.

She never felt that she needs any job. But after her divorce she started teaching Quran Pak to small

children and earns money for herself. After her second marriage she left this work and lives with her

husband.

Marital history The client was married first time when she was twenty nine years old. Her

married life was not satisfied. Her husband belonged to low class family. Her in-laws were not

sincere with her and does not show any respect towards her. Her husband did not love her and did

not show any care towards her. She did not like her husband too. Her marriage ended in six months.

After six month her husband gave her divorce. She was very depressed after her divorce.

After seven years she was again married because of her brother’s advice. She was very happy

from her second marriage. Her second husband was very loving and caring towards her. Her husband
 7

gave her so much love and care. She had spent satisfactory and healthy married life. But because of

her problems soon her married life was affected. She started to ignore her husband and felt

loneliness. She did not take interest in her marital life and most of the times feel depressed. After two

years of her marriage her husband gave her divorce. She thought that she was responsible for her

divorce because she did not give her husband love, time and emotional support.

Premorbid personality The client usually tends to be social and outgoing with family and

outside family with her friends since her childhood. Being younger in her family she always took

love and care from her family. She was very sensitive by nature.

She has many interests especially she used to enjoy shopping, gatherings with friends. But

her interests were diminished when her problems started. She had also developed interest in Islamic

teachings usually in her stressful time. She loved to read Islamic history. She was very talkative.

After the death of her father she may have developed changes into her personality and did not take

interest in any social activities.

Psychological assessment

Psychological assessment of the client was carried out on two levels including Informal and

Formal assessment.

 Informal assessment

 Formal assessment

Informal assessment

The informal assessment included

 Clinical interview

 Mental state examination

 Subjective rating of symptoms

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 Informal assessment

Clinical interview It is a face to face conversation in which clinician asks questions of client’s

problems, their reactions and responses. Clinician collects the detailed information about the

person’s feelings, problem, life styles, personal history and their relationships (Comer, 2004). In

clinical interview trainee take history of childhood, educational history, marital history, social and

occupation history. Client’s predisposing, precipitating and maintaining causes of the illness were

investigated.

In clinical interview the detailed and comprehensive history of the present illness was taken

and family history of the client was also explored in depth. During the clinical interview client show

trust and was very cooperative towards trainee. Over all functioning of the client and the general

atmosphere of the home was discussed thoroughly in clinical interview. She felt no hesitation in

revealing her own problems and issues. She reported all her information to trainee.

Mental state examination MSE is a well-planned method of describing and observing a

client's current state of mind, in the domains of appearance, speech, thought process, thought content,

perception, attitude, cognition, insight, behavior, mood and affect. The overall purpose of the mental

state examination is to bring out the patient’s psychopathology that is their abnormal subjective

experiences, and an objective view of their mental state, together with unusual behavior (Geddes,

2012).

The client age is 48 year old with normal weight and tall height. She has combed hair during

the session. She appeared in session with full confidence and good mood. She was dressed in neat

and clean clothes. Her personal hygiene was good nails are neat and clean and brushed her teeth. Her

behavior was well mannered towards trainee. She maintains eye contact during her sessions. Client

attitude towards internee was friendly, open and cooperative. Her level of consciousness was alert

and attentive.
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Her mood was energetic and affect was appropriate according to situation. Her thought

processing was goal directed and organized. Her abstract thinking was good. Her memory functions

i-e recent, remote and immediate was also intact. During the examination she seemed alert and was

sitting on the edge of her chair, maintaining a rigid vigilant posture. No hallucinations were reported.

Suicidal ideation and homicidal ideation was not present. Orientation to time, place and person was

intact. Her attention and concentration was good. She had insight about her illness.

Subjective rating of symptoms The subjective rating of symptoms was taken from the patient to get

an estimate of the intensity of the symptoms at the pre-treatment level in order to compare it with

post-treatment levels to gauge the effectiveness of the therapy. Rating of the symptoms was taken

from (0-10) for severity, 0= not at all, 5=average, 10=intense

Table 2

Table of subjective pre-treatment rating of presenting complaints

Symptoms Client’s rating

Aggressive behavior 8

Lack of interest in work 8

Depressed mood 8

Social withdrawal 7

Loss of control 8

Restlessness 8

Formal assessment

The formal assessment included

Young Mania Rating Scale YMRS is one of the most frequently utilized rating scales to

assess manic symptoms. YMRS consists of 11 items was administered on the client. It was

administered as a sort of interview from the client. The YMRS was able to screen out the symptoms
 10

of mania in the client. The goal of each item is to rate the severity of that abnormality in the patients

hospitalized for mania. It took 15 minutes to administer the test. Proper instructions were also

provided to the client before the test administered.

Quantitative Analysis

Table 3

The client’s raw score on the Young Mania Rating Scale

Raw Score Cut off score Interpretation

22 20 Presence of manic symptoms

Qualitative interpretation

The client’s raw score on the scale was 22 which show the presence of manic symptoms. The

results of the test applied on the client placed her among the category of manic individuals. Her

results are consistent with the symptoms she was experiencing. The client obtained the raw score of

22 which are far above the cutoff of 20.

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Case conceptualization

Conceptualization of bipolar disorder (adapted from Basco & Rush, 1995).

Mood shifts

When she feels depressed

Biological symptoms Changes in thought and

feelings
Decrease need for
sleep Feels loneliness

Experience stress

She feels
discomfort and Changes in behavior
‘’ irritability
Aggressive behavior

Continuously writes
stories and her
thoughts.
Psychosocial problems

Affect her married and

social life

Changes in psychosocial
functioning

Does not take interest in

daily activities
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Case formulation

48 years old female was referred to trainee for the assessment and management with the

presenting complaints of aggressive behavior, irritability, and feeling of loneliness, sleep

disturbance, depressed mood, loss of interest in work and daily activities and loss of control.

According to the DSM V the criteria for diagnose a person with bipolar I disorder includes

the person with this disorder must met the criteria of one manic episode. A manic episode may have

been proceed by and may be followed by hypo manic or major depressive episodes. In our case the

client had the goal directed activity, her depressed mood affect her social, occupational functioning,

diminished interest in activates and excessive and inappropriate guilt.

Beck’s original cognitive model (1967) suggests that depressed mood states are accentuated

by patterns of thinking that amplify mood shifts. For example, as people become depressed they

become more negative in how they see themselves, their world and their future. Hence they tend to

jump to negative conclusions, over generalize, see things in all-or-nothing terms, and personalize and

self-blame to an excessive degree (cognitive distortions). Changes in behavior, such as avoidance of

social interaction, may be a cause or a consequence of mood shifts and negative thinking. In our case

the client was also develop negative thinking for her that she was responsible for her divorces, she

was not able to fulfill her husband needs. She may developed inappropriate guilt and blamed herself.

Ellicott, Hammen, Gitlin, Brown, and Jamison (1990) theorized that life stress, in the form of

the kinds of negative life events already shown to be associated with the onset of unipolar

depressions (Brown & Harris, 1979; Paykel & Tanner, 1976), was also relevant for the course of

bipolar disorder. In this case the client was faces the traumatic life stress in the face of her father

death. After the death of her father she started the symptoms of bipolar disorder.

Hollon, Kendall and Lumry (1986) who reported that, compared to healthy control subjects,

individuals with either unipolar or bipolar depression showed higher levels of dysfunctional attitudes

and negative automatic thoughts.

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Diagnosis

According to the DSM V criteria the client was diagnosed with bipolar I disorder (F31.12)

Client’s Prognosis

The prognosis of the client was good because she had good insight regarding her problems

and she was motivated to resolve them. Further she was compliant towards the treatment as

therapeutic strategies.

Management plan

Management plan was design to help the client to manage and reduce her problematic

behavior, change her life patterns, control and manage her anger and make her motivated to actively

participate in the treatment and interventions.

Short term goals

 To build therapeutic alliance

 To educate the client

 To regularized the client’s daily routine

 To teach the client effective ways to control tension and make his body calm,

 To help her feel comfortable and relaxed.

 To help her notice and change her negative thinking patterns

 To teach client more appropriate activities

 To teach and engaged the client in social skill training.

Long term goals

 Strategies that implemented on her should be continue further in future in order to maintain

learned behaviors permanent and it will also help in learning more things.

 To teach the client appropriate relaxation and diversion activities, to decrease his level of dep

ression.

 To client family counseling should be carried out for the better treatment of the client.
 14

 Regular follow-up to be done to check the progress after the therapy.

Therapeutic intervention

For the management of the client eclectic approach were used. These enabled the client to

cope with problematic situations and behaviors.

Rapport building

Before the start of the assessment and management process the first step is to build

therapeutic relation with the client. Rapport was built by introducing the client with empathetic and

non-judgmental attitude. In the first session trainee therapist gave client a purpose of session. The

aim of interaction with the client was to build a harmonious relationship with her. In first session

trainee gives him empathetic attitude towards and build rapport with client and client felt

comfortable and did not hesitate to share her personal history.

Psycho education

Psycho-education was originally conceived as a composite of numerous therapeutic elements

within a complex family therapy intervention. In our case briefing the client about her problem,

develop a fundamental understanding of the therapy and further be convinced to commit to more

long-term involvement. (Bäumll, 2006). Psycho education is an integral part of treatment, beginning

at the start and essentially continually continuing throughout treatment (Wells, 1997).

Psycho education was provided to the client to develop an insight about the problem through

which the client was going through and about the effectiveness of the management and treatment. In

our case psycho education was only given to the client because her family members were not

available for psycho education.

Activity scheduling

Activity scheduling was design by Karol Adamiecki. This is the techniques of cognitive

behavioral therapy. The purpose of activity scheduling was to counteract the patient’s lack of

motivation, inactivity, psychomotor retardation and preoccupation with depressive ideas (Spigler &
 15

Guevremont, 1998). In our case the trainee suggested the client to follow these activities and make a

routine for herself. It was done to help the client to bring her routine on a streamline. Walk two times

a day, exercise and several other activities was suggested to the client to regularize her routine.

Progressive muscle relaxation

Progressive Muscle Relaxation was taught to the patient by giving her the rationale, that it

would help her relax physically and mentally and to reduce tension in her body muscles, by

systematically relaxing the group of skeletal muscles. The rationale of reciprocal inhibition behind

the procedure of tensing and relaxing the muscles was also explained to the patient (Spigler &

Guevremont, 1998).

The trainee gives instruction to the client that first slows down your breathing and gives

yourself permission to relax. In progressive muscle relaxation exercises, trainee asked the client to

tense up particular muscles and then relax them, and then you practice this technique consistently.

Relax the muscles and keep it relaxed for approximately 10 seconds. It may be helpful to say

something like “Relax” as you relax the muscle. When the client has finished the relaxation

procedure, remain seated for a few moments allowing the client to become alert. She was advised to

do it 3-5 times a day.

Deep breathing

Deep breathing is the demonstration of breathing profoundly from the gut. This includes

taking in from the nose, holding it in, and breathing out from the mouth (Miltenberger, 1997). This is

intended to make one feel relaxed. In this case the trainee used this technique with the client to teach

her to relax, when she was in distress or was feeling angry and upset over something. The client was

performing this step in front of the trainee and then the client feels relax. At the end of deep

breathing session it is asked to take a little time to scan one's body for tension and to compare it with

the tension he felt before the exercise. (spiegler & Guevennont, 1998).
 16

Cognitive restructuring

Cognitive restricting is the technique of CBT that are developed by Aron Beck. Cognitive

restructuring is a psychotherapeutic cycle of figuring out how to recognize and question maladaptive

thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking,

over-generalization, magnification, and emotional reasoning, which are commonly associated with

many mental health disorders (Ryan, Martin & Dahlen, 2005).

In our case it was carried out to help restructure the distortions in the thinking. In our case

cognitive restructuring helps the client to identify overly-negative habits of thinking which lead to

overly-negative mood states. The client changes her thought (I was failed to make happy my

husband) with the new one that everything was not in our control.

Behavioral activation

Behavioral activation has a long and positive history in the treatment of depressions.

Behavioral activation is the technique of cognitive behavioral therapy design by Martell et al. The

behavioral activation aims to help the client to engage more often in enjoyable activities and improve

their problem-solving skills.

In this case the trainee engaged the client in extra activities to participate in milad, write

something that was more pleasurable to her. The client set her activates and also stitch clothes and

learn new category of dress designing. She may develop interest in these activities.
 17

Table 4

Table of subjective post-treatment rating of presenting complaints

Symptoms Client’s rating

Aggressive behavior 7

Lack of interest in work 6

Depressed mood 7

Social withdrawal 6

Loss of control 7

Restlessness 6

Limitations

 The client’s family wasn’t available that’s why most of the information couldn’t cross

checked.

 Because of the non-availability of the client’s family member, there were gaps in family

history.

Suggestions

 Client family should be supportive towards her.

 Family therapy should be done for the more affective results.

 More session would be conducted for the treatment of the client.

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Session Report

1st Session (35 minutes)

In the first session the presenting complaints of the client were obtained by herself as well as

initial observation was gathered. Client interview was conducted. To obtained the details history

regarding the problems of the client including the history of present illness, personal history and

family history. The report was also started to build with the client gained trust and rapport was built.

2nd Session (40 minutes)

Second session was conducted to be known about her general information, medical status and

employment status. Psycho education was provided to the client about illness, treatment, clinical

course and prognosis.

3rd Session (35 minutes)

The goal of the session was to do Mental State Examination (MSE). Questions were asked to

know about her current mental functioning level. To know about the severity of the client’s problem

and subjective rating of the symptoms were taken from the client. Informal Assessment was

completed.

4th Session (40 minutes)

The goal of the session was to apply YMRS scale on the client to know about the severity

level of illness and tell the client that how to relax herself through deep breathing. On the other hand,

PMR and positive coping statements was also taught to client. Deep breathing and PMR was done

with client. To develop the understanding in her that she could relax herself with the help of these

techniques. The client came to know that she could make herself relax when she felt tensed or

fatigue.

5th Session (35 minutes)

The goal of the session was to tell the client that how behavior skill training was helpful to

overcome the stress. Skills were practiced with the client. To develop the understanding in her that
 19

she could relax herself by doing work. The client came to know that she could make herself relax

when she felt sad or stressed.

6th Session (30 minutes)

The goal of the session was to made activity scheduling chart for the client. Conversation was

made with client so that her daily routine tasks could be maintained. To maintain her daily routine

Activity Scheduling Chart was made for the client.

 20

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(DSM-5®). American Psychiatric Pub.

Ausubel, D. P. (1980). What every well-informed person should know about drug addiction.

Burnham Inc Pub.

Comer, R.J. (2013). Abnormal Psychology (8thed.). USA: Worth Publishers.

Geddes, J., Price, J., & McKnight, R. (2012). Psychiatry. OUP Oxford. to psychiatric disorder.

In Progress in brain research (Vol. 223, pp. 63-76). Elsevier.

Frank, E. (2007). Treating bipolar disorder: A clinician's guide to interpersonal and social rhythm

therapy. Guilford Press.

Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania:

reliability, validity and sensitivity. The British journal of psychiatry, 133(5), 429-435.
 21

Case Summary

A.Y is 35 years old male. The clinical supervisor referred the client to the trainee clinical

psychologists for psychological assessment and management. The client come with the presenting

complaints of irritability, outburst of anger, craving for drug, body pain, and loss of interest in work

and daily activities, loss of control and overuse of opioid. Assessment was done on both the informal

and formal levels. For informal assessment, clinical interview, mental status examination was done,

and subjective rating of symptoms was taken, and for the purpose of formal assessment Drug Abuse

Screening Test (DAST) was administered. For the purpose of management Rapport building, Psycho

education, Activity scheduling, Progressive muscle relaxation, Deep breathing, Cost benefit analysis,

Motivational interview, Distraction method and Relapse prevention was done with the client.
 22

Bio data

Name A.Y

Age 35 years

Gender Male

Siblings 4

Birth order 3rd

Religion Islam

Marital status Married

Occupation Labor

Informant Client and his Wife

Reason for referral

The client was brought by his wife to the Haji Abdul Qayyum Trust hospital, Sahiwal with

the presenting complaints of irritability, outburst of anger, craving for drug, body pain, and loss of

interest in work and daily activities, loss of control and overuse of opioid. The clinical supervisor

referred the client to the trainee clinical psychologists for psychological assessment and

management.

Presenting complaints

Table.1

Presenting Complaints of the Client as Reported by the Client himself

Duration Presenting complaints

‫ سال‬6 ‫افہیم کا نشہ کرتا ہو‬
‫ سال‬3 ‫کاروبار پر توجہ نہں دیتا تھا‬
‫ سال‬3 ‫بہت غصہ آتاہ‬
‫ سال‬2 ‫چئن ی‬
‫ھوت ےھ‬ ‫ئ‬ ‫ےب‬
 23

History of present illness

The client was brought to the hospital for having complaints of experiencing the symptoms of

craving for drug, irritability, body pain, outburst of anger, loss of interest in work and daily activities,

loss of control, and dangerous behavior towards his wife due to excessive drug use for last 6 years

and having behavioral and relationship problems. The client reported that at the age of 29, he started

using drugs. In the bad company of his friends he takes cigarette and opioid first time in his life. His

friends persuade him if he use drugs then he have more energy and power for doing their work and

then developed it dependence due to the positive effects of the drugs. Client father was also use

cigarette and take drugs in small amount. He often saw his father to take drugs. Client bad company

of friends and childhood experience of father taking substance play a role of drugs addiction in

client.

According to his wife client decrease the use of drugs because his mother forces him to stop

use drugs. He obeyed his mother. He loved his mother and has a close relationship with his mother.

Before two years, in 2020 his mother died. After the death of his mother he was very depressed and

feels loneliness and loss of interest in daily activities. Death of his mother worsened his condition

gradually and he started to take drugs in large amounts.

According to his wife he did not take interest in his work and soon develop financial issues,

therefore his wife started work to run their house. He often uses abusive language and beat his

children and wife. He sells fridge and TV for the sake of drugs. He did not take interest in his

children and wife. Due to his bad financial condition, he was unable to buy drug due to which he had

cravings and used to beat his wife in return.

According to the client because of excessive use of drugs he felt body pain, irritability and

then he decided to take professional help and came for treatment.

 24

Background information

Family history The client belonged to the low socioeconomic status and lived with his wife

and children. Client father and mother had died a few years ago. Client’s father was a labor and his

mother was a house wife. His father and mother were uneducated. Client father also used cigarette

and took drugs in small amount. Client has good relationships with his parents. He loved his mother

and was very attached with her. After the death of his mother he feels depressed and use excessive

amounts of drugs. The client also reported that whenever he had a conflict with his wife, his mother

always supported him.

The client had two sisters and one brother who are married. The client has good relationships

with his sisters but have not much satisfied relationship with his brother. Client married thirteen

years ago with his wife. Client wife was uneducated and work as a maid in other houses. According

to his wife they have not much satisfied relationships with each other. Client has two sons and one

daughter. The age of client’s sons is 12 and 10 years and daughter is three years old. According to

his wife client beats his children and forces his sons to work in factory to run their house.

Home environment Client lived with his wife and children. The general home environment

was not healthy. Client and his wife used to fight a lot and he beat her whenever he was in anger.

According to the client his wife spent more time in her brother house and did not take interest in

client and his house. Overall home environment of the house was not much satisfied.

History of physical and psychiatric illness in family No incidents of physical and

psychiatric illnesses were reported in the family (parents and siblings).

Personal history The client was born by a normal delivery at home. There were no prenatal

and post natal complications. He achieved all his developmental milestones at age appropriate level.

There was no history of any serious physical illness or trauma during childhood. Moreover, there

were no behavioral problems or neurotic habits in him like thumb sucking, nail biting. He did not
 25

have any allergies and no major injury was reported by the client and informant. There was no

history of bed wetting, temper tantrum, social withdrawal in early childhood.

Educational history The client is uneducated person. He belonged to a low socio economic

status family therefore his parents did not admit the client in school. When the client was five years

old his parents admit the client in government school but the client did not like the environment of

the school and also not showed interest in studies therefore he left the school. He left studies because

he did not like to go to school and study. He took education as burden. He spent his time to play with

his friends. His Islamic education was started at the age of seven. He did not offer prayers regularly.

Occupational history The client started working at the age of 18. He started his work from

toys stall. He sale toys and also worked in shop as a labor. Initially he worked very hard and took

interest in his work but as he indulged in the bad company of his friends due to which he started

taking drug “opioid” after which he lost his interest in his work and all other social activities. He

wasted his time and money in drug addiction.

Marital history The client got married ten years ago in 2012. His wife was from a low

socioeconomic class; she was illiterate. When the client was married he was satisfied with his

marriage and reported satisfactory relationship with his wife. She was loving and caring. They had

three children. According to client’s wife their relationship was affected because of drug addiction.

After taking excessive drugs and in the influence of drugs he often use abusive language because of

this their marital relationship suffered a lot, as he also started to beat his wife on small things. She

also reported that they were suffering from lack of money and her husband’s daily demand of money

for his drug was the major cause of their quarrel. Therefore, their relationship was not much

satisfactory and did not spend much happily married life.

Premorbid personality The client is extrovert and was fond of making lots of friends. He

shared his secrets with his friends. According to the informant, he had a positive view about

everything, he believed in himself. He had an appropriate and good interaction with his family. He
 26

had no history of physical or mental disorders. When he was not a drug addicts he pay attention to

his work and his family and social activities. But when he started to take drugs, the outburst of his

anger increased, he used to beat his wife when he was not able to get money to buy drug.

Psychological assessment

Psychological assessment of the client was carried out on two levels including Informal and

Formal assessment.

 Informal assessment

 Formal assessment

Informal assessment

The informal assessment included

 Clinical interview

 Mental state examination

 Subjective rating of symptoms

Informal assessment

Clinical interview A clinical interview is a conversation between a psychologists and client

that is intended to help the psychologist diagnose and treat the patient. The interview serves not only

to collect information, but also to establish a therapeutic relationship (Geddes, 2012). Clinical

interview was conducted to obtain a detailed history of presenting complaints, Substance

Dependence, personal history, family history, educational history, occupational history, marital

history and premorbid personality of the client. Confidentiality was ensured so that the client could

not hesitate to provide his information to the examiner. During the clinical interview the client was

very cooperative and feels comfortable to give his personal information to examiner. The

information discerned from the client was cross-checked by the informant. Predisposing,

precipitating and maintaining factors of the substance use along with overall functioning were
 27

explored in clinical interview. The information was then used to devise case formulation and

management plan for the client.

Mental state examination MSE is a structured way of observing and describing a client's

current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech,

thought process, thought content, perception, cognition and insight. The goal of the mental state

examination is to elicit the patient’s current psychopathology that is their abnormal subjective

experiences, and an objective view of their mental state, including abnormal behavior (Geddes,

2012). The client was 35 years old with a normal height. His complexion was dull. He was clean

shaved. His personal hygiene was good. He was wearing shalwar kameez. He seems to be dull, and

in low mood in first session but after two sessions he seemed to be comfortable and in a good mood.

His thought process and thought content were adequate and appropriate to the information provided

by the informant. He sat with a curved posture, did not show any spontaneous or awkward

movements and his shoulders were inclined downwards. He was alert and gave answer to the every

question appropriately. Speech was normal. Mood was serious and his affect was appropriate

according to the mood. Client orientation of time place and person was good. His perception was

good. Depersonalization, derealisation, and obsessional phenomena were absent. He stated that he

was guilty of using drugs and wants to get rid of this addiction. He had insight of his illness. He was

co-operative during the interview.

Subjective rating of symptoms The subjective rating of symptoms was taken from the

patient to get an estimate of the intensity of the symptoms at the pre-treatment level in order to

compare it with post-treatment levels to gauge the effectiveness of the therapy. Rating of the

symptoms was taken from (0-10) for severity, 0= not at all, 5=average, 10=intense
 28

Table 2

Table of subjective pre-treatment rating of presenting complaints

Symptoms Client’s rating

Irritability 9

Lack of interest in work 8

Craving 9

Social withdrawal 7

Aggression 9

Restlessness 9

Formal assessment

The formal assessment included

 Drug Abuse Screening Test

Formal assessment

The Drug Abuse Screening Test; was developed by Harvey A. Skinner PhD, in 1982.

DAST was used for assessment of the client. DAST helped us to probe information about client

involvement with drugs. This instrument took approximately 5 minutes to administer. The DAST

provides a brief, self-report instrument for population screening, identifying drug problems in

clinical settings and treatment evaluation.

Quantitative interpretation

Raw score Category

13 Substantial
 29

Qualitative interpretation

The client obtains 13 raw score on the drug abuse screening test which means that the client

must have a substance abuse problem.

Case formulation

A 35 years old man was referred to the trainee for the assessment and management with the

presenting complaints of irritability, outburst of anger, craving for drug, body pain, loss of interest in

work and daily activities, loss of control, overuse of and opioid.

According to the DSM V opioid use disorder includes craving or a strong desire or urges to

use substance. Because of opioid use person personal life, social, occupational or recreational

activities are given up or reduced. Recurrent opioid use in situation in which it is physically

hazardous. In this present case the client reported the craving of heroin. His family environment was

also badly affected by the use of heroin. As he become aggressive and use abusive language with his

wife.

Humanist view proposes that there are ordinary conditions of mindfulness, which are not

quite the same as normal cognizance and they assist the individual with adjusting different

circumstances. A few people may have less capacity to accomplish this mindfulness because of

nervousness or other obsessive states and they utilize the drugs as a way to accomplish typical

conditions. In this case the client was depended on drugs because of that in a state of depressed

feelings he rely on drugs to cope up with undesirable situation.

The psychoanalytic view believes that individuals might use drugs due to their inadequate-

personality coping with life problems. In this case the client use excessive drugs because of that he

does not cope after the death of his mother. Whenever he feels depressed he may use drugs to cope

this situation.

According to learning theory, addiction is simply a learned behavior. In other words, people

learn to engage in addictive behavior according to well-established learning principles. People may
 30

learn addictive behavior through classical conditioning by pairing the pleasure of addictive

substances or activities, with environmental cues. In this case the client has a belief that whenever he

uses drugs than he has a more power and strength for work therefore he uses drugs when he wants to

do work.

Coggans and McKellar (1994) suggested that drug using peers somehow pressure or give

confidence for drug use in their non-drug using peers. Peer preference is a more reasonable

interpretation, such that those inclined to the use of opioid deliberately associate with others

(Sznitman, Olsson &s Room, 2008).

A recent review of high quality studies assessing the relationship between opioid and mental

health found the following factors to be associated with the onset of opioid disorder: being male;

prior or concurrent tobacco and alcohol use; having poor parental relationships; and having peers

who use poly substance (National Institute on Drug Abuse, 2012). Lee and colleague recognized

various intentions for opioid use including conformity; experimentation; social enhancement;

boredom; relaxation; coping; availability; perceived low risk; altered perception; activity

enhancement; rebellion; alcohol intoxication; food enhancement; anxiety reduction; image

enhancement; celebration; medical use; and habit. The first six of these reasons for opioid disorder

were the most highly endorsed (NIDA, 2012). In this case the client found addiction of drugs as

pleasurable activity and coping with stressful situation.

Diagnosis

According to DSM-V client was diagnosed with 304.00 (F11.20) Moderate Opioid use

disorder.

Management plan

Management plan was design to help the client to manage and reduce the substance

dependence, change his life patterns, control his cravings for the drug, to manage his anger, and

make him motivated to actively participate in the treatment.

 31

Short term goals

 To build therapeutic relationship

 To give awareness to client and his family

 To regularized the client’s daily routine

 To teach the client effective ways to control tension and make his body calm.

 To help him feel comfortable and relaxed.

 To teach and realize the client that how drug dependency costing him without any benefit.

 To motivate the client to be an active part of the treatment.

 To educate client how to distract himself easily from the cravings of having the drug.

 To help out the client to identifying the triggers and situation that makes him vulnerable to

use drugs.

Long term goals

 Short-term goals will be continued for the desired outcome.

 Problem solving and Assertiveness Training

 Further follow up sessions will be continued to monitor and assess the patient’s functioning

and thus to avoid relapse.

 Relapse prevention strategies will be devised to help identify early warning signs for relapse.

Summary of therapeutic intervention

For the management of the client different therapies and techniques were used. These were

enables the client to cope with problematic situations.

Rapport building

Rapport was started building by introducing the client with empathetic and non-judgmental

attitude. In the first session gives client a purpose of session. The aim of interaction with the client

was to build a harmonious relationship with him.

 32

Psycho education

The patient was psycho-educated regarding her addiction, etiological and maintaining factors

were discussed with them. Psycho-education is an integral part of treatment, beginning at the start

and essentially continually continuing throughout treatment (Wells, 1997). The patient was also told

about the symptoms and nature of addiction and to evaluate the effects of drugs on different areas of

life including physical health. In present case psycho education will be helpful in educating family

members of client about the condition and the treatment of the client to provide information about

drug addiction and therapies.

Activity scheduling

Activity scheduling was design by Karol Adamiecki. This is the techniques of cognitive

behavioral therapy. The purpose of activity scheduling was to counteract the patient’s lack of

motivation, inactivity, psychomotor retardation and preoccupation with depressive ideas (Spigler &

Guevremont, 1998).

During session the activity scheduling worksheet was given to the patient to follow and the

informant was asked to monitor his activities. It was done to help the patient to bring his routine on a

streamline. The trainee suggested that daily check your personal hygiene, follows rules and in free

times read Quran Pak. Activity schedule divert client’s attention from drugs to other activities as a

coping strategy.

Progressive muscle relaxation technique

One method of reducing muscle tension that people have found helpful is through a

technique called Progressive Muscle Relaxation (PMR). In progressive muscle relaxation exercises,

you tense up particular muscles and then relax them, and then you practice this technique

consistently. The rationale of reciprocal inhibition behind the procedure of tensing and relaxing the

muscles was also explained to the patient (Spigler & Guevremont, 1998).
 33

In progressive muscle relaxation exercises, you tense up particular muscles and then relax

them, and then you practice this technique consistently. The trainee gave instruction to the client that

first slows down your breathing and gives yourself permission to relax. Relax the muscles and keep

it relaxed for approximately 10 seconds. It may be helpful to say something like “Relax” as you relax

the muscle. When the client has finished the relaxation procedure, remain seated for a few moments

allowing the client to become alert. He was advised to do it 3-5 times a day.

Deep breathing

The rationale of deep breathing was given that it would help her to defuse the physical effects

of the stress response and release the body tension and stiffness whenever she did the exercise

(Davis, 2000).

In breathing techniques, you place one hand on your chest and the other on your belly. Take a slow,

deep breath, sucking in as much air as you can. As you are doing this, your belly should push against

your hand. Hold your breath and then slowly exhale.

In first step he taught that Inhale slowly and deeply through your nose. Keep your shoulders

relaxed. Your abdomen should expand, and your chest should rise very little.

Then in next step Exhale slowly through your mouth. As you blow air out, purse your lips

slightly, but keep your jaw relaxed. You may hear a soft “whooshing” sound as you exhale.

Cost benefit analysis

Cost benefit analysis was developed by R. Laynard, D. Clark, M. Knapp, G. Cost benefit

analysis is the technique of cognitive behavioral therapy. This technique helped the therapist to

unblock many types of unhelpful behaviors such as impulsive behaviors, rituals, and procrastination.

It can also help to identifying the cognitive and behavioral factors that maintain difficulties

sometimes lead naturally to what we need to do next.

 34

Motivational interview

It is a goal-oriented, client-centered counseling style for eliciting behavior change by helping

clients to explore and resolve ambivalence. The approach attempts to increase the client's awareness

of the potential problems caused, consequences experienced, and risks faced as a result of the

behavior in question. Motivational Interviewing is a method that works on facilitating and engaging

intrinsic motivation within the client in order to change behavior (Miller & Rollnick, 2012).

Distraction method

Distraction technique will be used in order to change his focus of attention from craving. The

following are brief descriptions of commonly used distraction techniques, client asked to concentrate

their attention on describing their surroundings, such as cars, people and trees etc. These activities

can be quite challenging and therefore require focused concentration (Beck, Wright, Newman, &

Liese, 1993).

The more they can focus and give details about these external events, the more likely they are

to focus less on the internal cravings. The client would be suggested to use talking to distract which

involve starting a conversation with a friend, a relative, a support group, or the therapist. Patients can

also remove themselves from the cue laden environment. They can take a brisk walk, visit a friend,

or go for a drive. Encourage the client to recite or write down a favorite poem or prayer. Suggest that

patients spend time involving in games, such as cards, video games, board games, and puzzles.

Relapse prevention

A list of coping techniques will be generated which patient can use in problematic situations

and can manage him by following them. Patient will also be educated about the medication

adherence and monthly regular checkups to avoid the relapse and also for the booster sessions by the

appointed clinical psychologist.

 35

Table 4

Table of subjective post-treatment rating of presenting complaints

Symptoms Client’s rating

Irritability 7

Lack of interest in work 7

Craving 7

Social withdrawal 6

Aggression 7

Restlessness 8

Limitations

 Client was on medication, so he was sleeping daytime; this creates difficulty in the way of

goal achievement.

 After treatment client live in the same environment from where he starts drug use, so there is

chance of to drug use

Suggestions

 Strategies that implemented on him should be continue further in future in order to maintain

learned behaviors permanent and it will also help in learning more things.

 Client not to go in the company of his old drug user friends.

 Client family should be supportive towards him.

 36

Session Report

1st Session (35 minutes)

In the first session the presenting complaints of the client were obtain by his informant as

well as initial observation was gathered. Client interview was conducted. To obtained the details

history regarding the problems of the client including the history of present illness, personal history

and family history. The report was also started to build with the client gained trust and rapport was

built.

2nd Session (40 minutes)

The goal of the session was to do Mental Status Examination (MSE) and applying Drug

Abuse Screening Test. Assessment Scale was applied and questions were asked to know about his

current mental functioning level. It was used to know about the severity of client’s problem.

3rd Session (35 minutes)

The goal of the session was to do Psycho-education by showing him ABC model. Psycho-

education was done with the client to develop the awareness about his problem. To give the insight

to client regarding his illness, nature of problem and other contributing factors. Assessment was

completed also client understands and identifies various environmental factors which contributed to

these factors. Client understands the ABC model.

4th Session (40 minutes)

The goal of the session was to tell the client that how to relax himself and PMR was also

taught to client. PMR was done with client. To develop the understanding in him that he could relax

himself with the help of these techniques. Client came to know that he could make himself relax

when he felt stressed or fatigue.

5th Session (40 minutes)

The goal of the session was to teach the client that how to distract him when he felt cravings

for drugs. Distraction techniques were taught to client. When he felt the urge to take drugs he could
 37

easily distract him so he could cope with his cravings and concentrate on other things. Understanding

about distraction was developed. He came to know that he could deal with his cravings.

6th Session (40 Minutes)

The goal was to do Cost Benefit Analysis. Costs and benefits were written on the pages by

client. So he could understand that how his addiction is disturbing him and had more disadvantages

than advantages. He came to know about the advantages and disadvantages of his addiction.

7th Session (40 minutes)

The goal of the session was to do Motivational Interview. During the session trainee motivated the

client by gives motivational interview in which the trainee addressed him about the problems and

effects of drug addiction and benefit of the therapies.

 38

References

Volkow, N. D. (2014). America’s addiction to opioids: Heroin and prescription drug abuse. Senate

Caucus on International Narcotics Control, 14, [Link]

Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya Yogic breathing in the treatment of stress,

anxiety, and depression: part II—clinical applications and guidelines. Journal of Alternative

& Complementary Medicine..

Baider, L., Uziely, B., & De-Nour, A. K. (1994). Progressive muscle relaxation and guided imagery

in cancer patients. General Hospital Psychiatry.

Dickstein, J. M. (2018). For the Love of Nonhumanity: Anxiety, the Phallus, Transference, and

Algorithmic Criticism. In Lacan and the Nonhuman (pp. 249-276). Palgrave Macmillan,

Cham.

Sadruddin, S., Jan, R., Jabbar, A. A., Nanji, K., & Tharani, A. (2017). Patient education and mind

diversion in supportive care. British Journal of Nursing, 26(10), S14-S19.

Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford

University Press. p. 202.

David Barlow,v. Mark Dunrad. (2015) Abnormal Psychology (7th ed.). Stamford: Cengage

Learning.

Comer.R.J. (2015) Abnormal Psychology (9th ed). Newyork: Worth Publishers.

Sharf, R.S. (2012) Theories of psychotherapy and Counseling (5th ed.). Belmont, CA:

Cengage Learning.

Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1995). The

structure of the genetic and environmental risk factors for six major psychiatric disorders in

women: Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and

alcoholism. Archives of general psychiatry, 52(5), 374-383.

 39

Case Summary

Client name was D.A. He was 58 years old, male and educated up to matriculation. He had

experienced extreme weight loss, difficulty in sleep, sadness, loss of interest, crying, muscle tension

and low appetite.

Psychological assessment was done informal level which consists of History Taking,

Behavioral Observation, Mental State Examination and Subjective Ratings of Symptoms. Formal

assessment was done with the help of Beck Depression Inventory (BDI). According to the presenting

complaints and on the basis of assessment client was diagnosed with Major Depressive Disorder

(F32.2), Severe; with fair insight according to the diagnostic criteria of DSM-V.

The management plan would be compromised on rapport building, psycho education, deep

breathing, 16 progressive muscle relaxation (PMR), activity scheduling and written/ verbal

ventilation. The management plan of the client helped to control the muscle tension, stress and other

physiological problems. The therapy helped much in improving his stressful behaviors.
 40

Bio data

Name D.A.

Age 58 years

Gender Male

No. of siblings 3 (3 brothers)

Birth order 1st born

Education Matric

Occupation Shopkeeper

Marital status Married

Religion Islam

No. of sessions 6

Reason of Referral

The client was referred for the purpose of psychological assessment and management of his

problems.

Presenting Complaints

Table 1

Presenting Complaints and Duration of Client’s Problems Reported by client

Duration Presenting Complaints

‫ایک سال‬ ‫۔اداسی رہتی ہے‬1
‫دو سال‬ ‫ ۔کسی کام میں دل نہیں لگتا ہے‬2
‫دو سال‬ ‫ہوں‬ ‫۔روتا رہتا‬3
‫ایک سال‬ ‫۔نیند نہیں آتی ہے‬4
‫ایک سال‬ ‫۔وزن بہت کم ہو گیا ہے‬5
‫ایک سال‬ .. ‫۔پٹھوں میں کھچاؤ رہتا ہے‬6
‫دو سال‬ ‫ ۔بھوک کم لگتی ہے‬7
 41

Initial Observation

It has been observed that the client’s dressing was appropriate to the season. And the client’s

mood was low. He has normal eye contact. Increase rate of speech and normal volume.

History of Present Problem

As reported by the client, his problem stared in 2020 when he was told that his sons decided

to take him to the old house after his wife’s death. His sons not ready to accept him and want him to

go from their house. According to the client he was punished by his sons because he beaten their

mother in anger and he get her out of the house. After this incident he would start to feel low. He felt

himself as a rejected person and often cried secretly. His confidence was badly shattered as

everybody rejected him. He began to decrease his appetite. He felt himself as a failure. He was very

social and active. According to the client he was running a shop to earn money for his home. He can

do lot things and met people who came to his shop. In October 2021, his life was disturbed and he

did consult a psychiatrist/ psychologist but did not improve much.

Background Information

Personal History

As a child he was very naughty. He was interested in playing kite flying and playing cricket

from his childhood. He was least interested in studies and parents were least concerned about their

child’s studies.

Family History

Client’s father died in 1995. According to the client, he was a strict person. He said that he

was in a good relationship with him. Mother died in 1998. According to the client her mother was

died due to diabetes. He said that his mother was a housewife. Brother is 49 years old, educated

person. Client said that his brother lives in his own property or house with his wife and 4 children.

He has his own shop where he did work. According to the client, his relationship with him was very

close. He often came to visit him and bring some food and clothes for him and second brother is 38
 42

years old, educated up to F.A. Client said that his younger brother lives with family and a clerk in

government health department. According to the client, her younger brother is very social. He is a

married man with no children.

Educational History

He started his school at the age of 5 years. His physical health was good. According to client,

he was no much pampered child, did not get a lot of love and attention from others. Now he had

studied up to matriculation classes.

Marital History

The client was married at the age of 19 years. According to the client, the relation with his

wife was not good. As she does all the work of his home and cares for his children. But sometime

she do wrong thing and in result beaten by him.

Pre morbid Personality

The client reported that he was a jovial person. He used to think very positive. Client reported

that he wanted to spend most of his time with books. He remained alone most of the time. He came

here where he started meeting fewer and fewer people. He wanted to be alone most of the time.

History of Medical Illness

The client did not have any history of psychiatric or medical illness in his family. His birth

also normal and milestone are appropriate. According to the informant the client was normal in his

childhood and no one in his family has this type of illness.

Assessment

Informal Assessment

 History Taking

 Behavioral Observation

 Mental State Examination

 Subjective Ratings
 43

Formal Assessment

 Beck Depression Inventory (BDI)

Informal Assessment

History Taking Clinical interview was conducted to obtain comprehensive information

about client’s family history, educational history, personal history, sexual history and premorbid

personality (Stanley, 2008)

History was taken in to two sessions. Informant was his father and also himself. In history,

past and present problem history, medical, psychiatric history, sexual history, home environment,

school and college period, early development was included. A detailed clinical interview was

conducted with the client that resultant in identifying the incident of (after his wife death, his son

decides to take him to his old home. His son is not ready to accept him and wants him to leave his

house). As triggering factor, and the (client did not have a good relationship with his son) as the

maintaining factor of the client illness. This all helped the therapist make a diagnosis and devise a

management plan. Informed consent was taken and confidentiality was ensured.

Behavioral Observation Behavioral observation is a functional, utilitarian approach in that

it focuses on the clearly observable ways in which the client interacts with his or her environment.

Behavioral observation may be used informally as part of an interview (Hintze, 2007).

At the start of first session the client was little nervous. He was sitting properly and he was

maintaining eye contact. His sitting gesture was comfortable. He was speaking in very low tone of

voice. His speech was not in a continuous manner.

Mental State Examination (MSE) MSE is a useful diagnostic tool in psychiatric practice. It

is a semi structured method for describing the clients’ mental state and behaviors at a given moment.

Diagnostic and therapeutic decisions about client are based on the findings of MSE (Trzepacz &

Baker, 1993)
 44

Appearance. Mr. B.A. was a timid man. Short hair not combed properly, wearing light color

suit. His hair color was brown. His skin color was dark. His height was 5 feet and 7 inches. His

weight was 58 kg. His apparent age was similar to his chronological age.

Attitude. His attitude was very cooperative. He was properly responding all over the

interview. He did not resist during the history taking and willing to openly discuss his problems. He

was very respectful. He was having proper eye contact.

Behavior. He was not showing any psychomotor agitation.

Speech. His volume of speech was low but he could speak properly and was able to convey

his message.

Mood. His mood was mostly low. He was having low mood throughout the interview.

Thought Process Client expressed worry about himself and if he would be able to recover

from illness as his prior experience of doctors was not so good.

Thought Content. There were no signs of suicidal and homicidal ideation.

Orientation. He did know about time. He knew what place was that where he was sitting. He

had orientation of place. He knew the names of family members. He can recognize every one very

simply.

Perception. No hallucinations and delusions during the interview were present.

Memory and Concentration. He could remember many things but he was so confused and

forgetting very little detail. He had no memory issues. He knew what he had in breakfast. He tried to

listen his therapist attentively.

General Information/Intelligence. He had general knowledge about things. He replied to my

most of question asked simply from his daily life.

Insight. Insight was present.

 45

Subjective Rating. The client was asked to rate the problem from the range of “0-10” rating

scale in which the score lies above 5 would indicate the severity of the problem while the score lie

below the 5 would indicate the less severity or absence of the symptoms.

Table 2

Subjective Rating of the Problems by Client (Pre-assessment)

Presenting Complaints Rating

Weight loss 9

Difficulty in sleep 9

Sadness 10

Crying 8

Muscle tension 9

Loss of interest 9

Low appetite 9

Formal Assessment

Beck Depression Inventory (Aaron T. Beck, 1961). Each answer is scored on a scale value

of 0-3. It consists of 21 items. The score ranges were listed below:

0-3= Minimal, 14-19= Mild, 20-28= Moderate, 29-63= Severe

Table 3

Table Showing Scores in Beck Depression Inventory (BDI) Scale

Raw scores Range Severity level

50 29-63 Severe

Interpretation. The score of client on Beck Depression Inventory was 50 which indicated that

the depression was severe. Those items included the sadness, sleep and appetite disturbance,

weeping, worry, feelings of loneliness, fatigue and hopelessness. It was revealed from the history
 46

that his appetite and sleep was disturbing every time and he had the weeping spells. The client

seemed himself as worthless as he could not do anything as well as he was worrying most of the

time. Results showed that he was feeling himself alone and further feeling the fatigue every time. He

was feeling sadness due to the past memories and he was hopeless about him future. He thought that

mostly people were not able to trust. Overall, the results of that tool showed that the client was

suffering from the depression.

Diagnosis

According to DSM-5 the client was suffering from Major Depressive Disorder, Severe

(F32.2).

Client’s Prognosis

The prognosis of client was good because he had good insight regarding him problems and he

was motivated to resolve them. With counseling and medicine he can be back to his normal life.

Intervention Plan

Short Term Goals

 Rapport building was done to develop a trust worthy relationship. It was also done to make a

strong and healthy therapeutic relationship.

 Supportive work will be done.

 Psycho-education was done.

Long Term Goals

 Continuation of short term goals.

 Follow up sessions would be conducted.

 Stabilize the anxiety level.

Treatment

Techniques Applied

 Rapport Building
 47

 Psycho education

 Deep Breathing

 16 Progressive Muscle Relaxation (PMR)

 Positive Coping Statements

 Activity Scheduling

 Written/ Verbal Ventilation

Rapport Building Rapport building is necessary for building strong client-therapist

relationship. In order to build therapeutic bond rapport was built with the client (Dickstein, 2018).

Rapport building was done with the client. In initial sessions client looked stressed and have

low mood but after sometime he became comfortable. It was not so difficult to build rapport with the

trainee psychologist. He talked about his problems. It was made clear to the client that his

information will be kept confidential and used only for educational purposes.

Psycho-Education It is the process of providing education and information to those seeking

and receiving mental health services and their family members (De-Nour, 2014).

The client was educated about his problem. It was told to the client that his stress and worry

could be treated. He was provided with information regarding depression along with rationale of

different techniques which were to be used.

Deep Breathing It was told to the client that when he became tense or felt restlessness, he

should start deep breathing. Because with the help of deep breathing flow of oxygen increases in

blood. With the help of batter transport of oxygen in blood and brain her restlessness and

anxiousness decreases. Deep breathing is done when a person had trouble holding the breath or when

the heartbeat accelerated (Brown, 2005).

The patient was taught the method of deep breathing to practice a degree of mastery of his

symptoms of anxiety. He was told that he can use deep breathing for distraction of the stress and

whenever he felt like his anxiety thermometer start increasing, he could relax herself by using deep
 48

breathing. The patient was first asked to take long deep breath in order to evaluate his by putting one

hand at the chest and one hand at the abdomen. After that he was explained the right method of the

breathing that how he supposed to breath. The right method was demonstrated by the trainee

therapist and then he was asked to do deep breathing by inhaling the oxygen through the nose then

holding it for some time and exhale it through mouth. The patient was advised to deep breath daily

for twice a day so that he had enough practice for it to deep breath before his anxiousness made him

upset. In the next few sessions, the patient started reporting that he felt a sense of relaxation while

doing deep breathing though it not helps him in every setting but when he felt confused, he practiced

it and get a relief and it was helpful for sound sleep.

16 Progressive Muscle Relaxation Technique 16 PMR techniques were taught to the client.

It was told to her that how to tense and relaxed different muscles. It was told to her that how to

maintain concentration on one group of muscles and how it will help her during restlessness.

Relaxation was thought to the patient with the basic premise that the tense muscles would be relaxed.

The client felt pain in the body because of muscle fatigue so he was taught that muscle tension

somewhat related to his problem which makes him unable to feel relaxed (Baider, 2015).

The patient was thought 16 muscle relaxations. He was given the detailed description of the

technique. The client was provided with the clear instructions about how he supposed to create

tension in the muscle and then felt relaxed. After explaining the rational of the technique, the client

were given demonstration to address the queries regarding muscle tension and relaxation. The client

was asked to practice PMR daily especially when he awakes in the morning. After 2 sessions he was

asked to practice it alone. The trainee therapist gets feedback from the client in every session. The

client reported that he felt better after practicing this technique.

Positive Coping Statements These are used to put a stop to the thoughts that lead to anxiety,

and to replace those thoughts with realistic, rational thoughts. When these rational self-statements are

practiced and learned, your brain takes over and they automatically occur. This is a form of gentle
 49

conditioning, meaning that your brain chemistry actually changes as a result of your new thinking

habits (Richard, 2014).

First use thought stoppage. Be gentle but firm about it. STOP! These thoughts are not good

for me. They are not healthy or helpful thoughts, and I have decided to move in a better direction and

learn to think differently. Then pick two or three statements that seem to help you, and repeat them to

yourself out loud each day.

Activity Scheduling Activity scheduling was done for the client in order to maintain his

daily routine. A chart was made for the client and told him to follow it for the maintenance of his

life. The most suited activity scheduling was devised for the client with her collaboration in order to

carry out daily activities on a schedule and to keep a person busy in healthy tasks. Focus of the

activity scheduling was on the day activities done by the client, practicing the relaxing techniques

thought to the client and to monitor inter personal relations of the client. Activity scheduling helped

him to resume the daily tasks done by the client. (Rupke, 2016)

Written and Verbal Ventilation Written/ verbal ventilation is a key healing process in

therapy and a key bonding process in intimacy. It is the metabolizer of emotional pain. It is speaking

or writing in a manner that airs out and releases painful feelings. When we let our words spring from

what we feel, language is imbued with emotion, and pain can be released through what we say or

write. Verbal ventilation technique will be used will be used to decrease in negativity and reduction

of stress (Cameio, 2013)

Pre and Post Management Subjective Ratings

Pre and Post Management Subjective Ratings were taken from the client and compare pre and

post-management ratings of the problems from client. Client had rated the problem out of the scale

of 0-10. 0 is the minimum problem and 10 means severe problem.

 50

Table 4

The Pre and Post Rating of The Client’s Problem

Presenting Complaints Pre-Assessment Post Assessment

Weight loss 9 8

Difficulty in sleep 9 7

Sadness 10 8

Crying 8 6

Muscle tension 9 7

Loss of interest 9 6

Low appetite 9 7

Total 63 49

According to the post assessment it was revealed that client’s symptoms severity decreases

after the application of different techniques included in management plan.

Limitations

 There was no sound proof atmosphere for the relaxation exercise of Progressive Muscle

Relaxation.

 The psychological assessment was often interrupted because of the on-going treatment of the

client.

Recommendations

 The client should come for the follow up sessions for the further management of his problems

to cope fully with his depression.

 Interview should be conducted in an environment that is free of any distractions or

disturbance
 51

Session Report

1st Session (35 minutes)

In the first session the presenting complaints of the client were obtain by his informant as

well as initial observation. Client interview was conducted. To obtained the details history regarding

the problems of the client including the history of present illness, personal history and family history.

The report was also started to build with the client gained trust and rapport was built.

2nd Session (40 minutes)

In second session was conducted to be known about his general information, medical status

and employment status. Psycho education was provided to the client about illness, treatment, clinical

course and prognosis.

3rd Session (35 minutes)

The goal of the session was to do Mental State Examination (MSE). Questions were asked to

know about his current mental functioning level. To know about the severity of the client’s problem

and subjective rating of the symptoms were taken from the client. Informal Assessment was

completed.

4th Session (40 minutes)

The goal of the session was to apply BDI scale on the client to know about the severity level

of illness and tell the client that how to relax himself through deep breathing. On the other hand,

PMR and positive coping statements was also taught to client. Deep breathing and PMR was done

with client. To develop the understanding in him that he could relax himself with the help of these

techniques. The client came to know that he could make himself relax when he felt tensed or fatigue.

5th Session (35 minutes)

The goal of the session was to tell the client that how positive coping statements and written

ventilation technique was helpful to overcome the stress. Positive coping statements were practiced

with the client. To develop the understanding in her that he could relax himself with the help of these
 52

statements and by writing out the inner sub conscious or conscious thoughts it will be good for his

catharsis. The client came to know that he could make himself relax when he felt sad or stressed.

6th Session (30 minutes)

The goal of the session was to made activity scheduling chart for the client. Conversation was

made with client so that his daily routine tasks could be maintained. To maintain his daily routine

Activity Scheduling Chart was made for the client.

 53

References

Baider, L., Uziely, B., & De-Nour, A. K. (1994). Progressive muscle relaxation and guided imagery

in cancer patients. General Hospital Psychiatry.

Dickstein, J. M. (2018). For the Love of Nonhumanity: Anxiety, the Phallus, Transference, and

Algorithmic Criticism. In Lacan and the Nonhuman (pp. 249-276). Palgrave Macmillan,

Cham.

Sadruddin, S., Jan, R., Jabbar, A. A., Nanji, K., & Tharani, A. (2017). Patient education and mind

diversion in supportive care. British Journal of Nursing, 26(10), S14-S19.

Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford

University Press. p. 202.

David Barlow,v. Mark Dunrad. (2015) Abnormal Psychology (7th ed.). Stamford: Cengage

Learning.

Comer.R.J. (2015) Abnormal Psychology (9th ed). Newyork: Worth Publishers.

Sharf, R.S. (2012) Theories of psychotherapy and Counseling (5th ed.). Belmont, CA:

Cengage Learning.

Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1995). The

structure of the genetic and environmental risk factors for six major psychiatric disorders in

women: Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and

alcoholism. Archives of general psychiatry, 52(5), 374-383.

Sadruddin, S., Jan, R., Jabbar, A. A., Nanji, K., & Tharani, A. (2017). Patient education and mind

diversion in supportive care. British Journal of Nursing, 26(10), S14-S19

 54

Case Summary

S.W was 32 years old female. She was referred to trainee clinical psychologist for the

purpose of psychological assessment and management with the complaints of restlessness,

palpitations, lack of concentration, irritability, social withdrawal and fatigue.

Psychological Assessment was carried out using History Taking, Mental State Examination

and Subjective Rating of Symptoms and Generalized Anxiety Disorder 7-item (GAD-7) Scale. After

taking complete history and psychological assessment, she was given the diagnosis of Generalized

Anxiety Disorder 300.02(F41.1), Moderate.

Management plan was devised for the client that included rapport building, psycho

education, vicious cycle, deep breathing, progressive muscle relaxation (PMR), activity

scheduling, and anxiety busting and distraction techniques. The therapies helped her much

in improving her anxiety, restlessness, muscle tension and fatigue.

.
 55

Bio data

Name S.W

Age 32 years

Gender Female

No. of siblings Nil

Birth order Single Child

Marital Status Unmarried

Religion Islam

No. of sessions 6

Reason of Referral

The client was referred to trainee clinical psychologist for the purpose of psychological

assessment and management of her problems.

Presenting Complaints

Table 1

Presenting Complaints reported by Client

Duration Presenting complaints

‫دو سال‬ ‫۔ ہر وقت بے چین رہتی ہوں‬1

‫ایک سال‬ ‫۔ دھڑکن تیز رہتی ہے‬2
‫ایک سال‬ ‫۔ کسی کام پر توجہ نہیں دے پاتی ہوں‬3
‫ایک سال‬ ‫۔ چڑچڑا پن رہتا ہے‬4
‫ایک سال‬ ‫۔ تھکاوٹ رہتی ہے‬5
‫ایک سال‬ ‫۔ لوگوں سے ملنے کا دل نہیں کرتا ہے‬6
 56

Initial Observation

Initially it was observed that Client’s hygiene was appropriate. She did not maintain proper

eye contact. She looked anxious and seated on the edge of the chair. Her voice tone was appropriate.

She used to ask about her medicines several times in a session. She was very conscious about her

food as she checked time again and again for food. She was aware of her problem.

History of Present Illness

Client’s problem started in 2019 when she was at the age of 29 years. She faced rejection

from three proposals. She started feeling restlessness and anxiousness all the time. She felt worried

about her future most of the time. Client reported that she started smoking in 2020. Her mother tried

to stop her from smoking but she was helpless in front of her condition. She also reported that after

smoking she got pleasure and relief from her worry. The problem got worse when her mother died in

2021. Although she had not very good relationship with her mother but this incident had made her

life worse. She had no one to support her or to look after her. She remained worried all the time and

symptoms of anxiety become worse. She had visited some doctor earlier but did not get good

response. Now on the recommendation of her neighbors she came to the hospital. Currently, she was

suffering from restlessness, palpitations, lack of concentration, irritability, social withdrawal and

fatigue. Due to the above-mentioned symptoms her neighbor took her to the hospital for assessment

and treatment.

Background Information

Personal History

She was born through C-section delivery. Client’s mother was under stress during pregnancy

due to conflicts in her marital relationship. Client achieved her developmental millstones at

appropriate age. Client was shy and sensitive by nature from her childhood. She did not trust anyone.

She liked to listened music. She was sensitive towards minor stressors. She also became worried

about minor situations. No history of neurotic traits was reported except nail biting in her childhood.
 57

Family History

Client’s father died at the age of 55 years. He was an engineer. He was aggressive by nature.

Client did not have any kind of contact with her father because her parents were divorced when she

was at the age of one month. Client’s mother died in 2021. She was a lady doctor. She was of

authoritative nature. Client had conflicting relationship with her mother. As her mother did not allow

her to go outside with her friends and always force her to follow her decisions.

Educational History

Client’s schooling was started at the age of 4 years. She passed her matriculation at the age of

17 years. She took gap for one year after matric and completed her F.A. when she was 20 years old.

She did her bachelor in Home Economics at the age of 22 years. She was an average student. She did

not participate in extra-curricular activities.

Sexual History

Client achieved puberty at the age of fourteen years. She got all the information about

maturation from her cousins so her reaction was normal. No history of homosexuality and

heterosexuality was reported. History of masturbation was reported once a month.

Premorbid Personality

The client personality before the onset of this problem was very anxious. Client reported that

she fear from things and she never sleep alone. She was afraid of the dark room and she faced

difficulty while staying alone at home. She had limited friends and did not trust anyone. She had no

medical problem and also she never had any fits throughout his life before the onset of problem. Due

to her family issues she usually got upset and kept on thinking about that situation for days. She had

poor problem solving skills. She did not take part in any social or extracurricular activities. She had

low frustration tolerance.

History of Medical Illness

The client had not suffered from any major medical illness.
 58

Assessment

Informal Assessment

 Clinical Interview

 Behavioral Observation

 Mental State Examination (MSE)

 Subjective Rating of Symptoms

Formal Assessment

 Generalized Anxiety Disorder 7-item (GAD-7) Scale

Informal Assessment

History Taking Clinical interview was conducted to obtain comprehensive information

about client’s family history, educational history, personal history, sexual history and premorbid

personality (Stanley, 2008)‫ ۔‬The interview was also conducted in such a way to know about the

precipitating factors and predisposing factors of the illness. It was also ensured that the client’s

information will be kept confidential.

Behavioral Observation Behavioral observation is a functional, utilitarian approach in that

it focuses on the clearly observable ways in which the client interacts with his or her environment.

Behavioral observation may be used informally as part of an interview (Hintze, 2007).

At the start of first session the client was little nervous. She was not sitting properly as she

was not maintaining eye contact. Her sitting gesture was uncomfortable. She was speaking in

appropriate tone of voice. Her speech was not in a continuous manner. She was watching here and

there.

Mental State Examination The mental state examination (MSE) is an important part of the

clinical assessment process in psychiatric practice. It is a structured way of observing and describing

a patient's psychological functioning at a given point in time. The purpose of the MSE is to obtain a

comprehensive cross-sectional description of the patient's mental state, which, when combined with
 59

the biographical and historical information of the psychiatric history, allows the clinician to make an

accurate diagnosis and formulation, which are required for coherent treatment planning (Trzepacz &

Baker, 2013)

Appearance. S.W was 32 year old female with appropriate height and weight. She had a fair

complexion and her grooming was adequate. She did not maintain proper eye contact. Her apparent

age was similar to her chronological age.

Attitude. Her attitude was much cooperative now. She was responding all over the interview

but anxiously. She did not resist during the history taking and willing to openly discuss her problems.

She was having very low of eye contact. She was watching here and there.

Behavior. She was showing psychomotor agitation. She was shaking her legs continuously

Speech. Her speech was clear, relevant, coherent and well understood and was of adequate

volume.

Mood. Her affect was sad. Her mood was mostly low. She was having anxious mood

throughout the interview.

Thought Process. Client expressed worry about herself and if she would be able to recover

from illness.

Thought Content. There were no signs of suicidal and homicidal ideation.

Orientation. She knew about time. She knew the exact time. She knew what place was that

where she was sitting. She had orientation of place. She knew the names of family members. She can

recognize every one very simply.

Perception. No hallucinations and delusions during the interview were present.

Memory and Concentration. Her short term and long term memory were intact. She could

remember many things but she was so confused and forgetting very little detail. Her recent, remote

or immediate memory was not intact. She knew what she had in breakfast but not much was

recognized by her. She had short attention span and low concentration.
 60

General Information/Intelligence. She had general knowledge about things. She replied to

all question asked simply from her daily life.

Insight. She had wisdom about things and knowledge about people. Insight was present.

Subjective Rating. The client was asked to rate the problem from the range of “0-10” rating

scale in which 0 means low anxiety and 10 would indicate severe anxiety.

Table 2

Subjective Rating of the Problems by Client (Pre-assessment)

Presenting Complaints Rating

Restlessness 7

Palpitations 7

Lack of Concentration 8

Irritability 8

Fatigue 8

Social Withdrawal 8

Formal Assessment

Generalized Anxiety Disorder 7-item (GAD-7) Scale. Generalized Anxiety Disorder Scale

(GAD-7) was developed by Janet B.W. Williams and colleagues consist on seven items. Validity of

this scale is mentioned by different articles and researches. The cut off scores are 0-4 for minimal, 5-

9 for mild, 10-14 for moderate and 15 for severe anxiety (Spitzer, 2001)

Table 3

Generalized Anxiety Disorder Scale of the Client

Total Scores Range Severity Level

14 10-14 Moderate
 61

Interpretation

Results revealed that client had moderate level of generalized anxiety as she scored 14 in the

seven item scale.

Diagnosis

According to DSM V the client was suffering from Generalized Anxiety Disorder, moderate

300.02 (F41.10)

Client’s Prognosis

The client was very much cooperative with the trainee psychologist and having a good insight

of her problem. With counseling and medicine, she can be back to her normal life; overall, the

prognosis was good.

Intervention Plan

Short Term Goals

 Rapport was built with the client. So the client would give correct information and establish

confidence on the therapist.

 Client was psycho-educated. In psycho-education therapist or psychologist teaches new ways

to cope with traumatic situations or events.

 Vicious Cycle was taught to the client to develop her understanding about her anxiety.

 Deep breathing was used to deal with the stress provoking situations.

 Progressive Muscle Relaxation Technique was used to deal with the tense muscles of the

client. It involves learning how stressful circumstances can cause the body’s autonomic

nervous system to activate.

 Activity scheduling was done with the client.

 Diversion Techniques were used to make the client able to distract him for the intrusive

thoughts.
 62

 Anxiety Busting Techniques were used to teach the client about intake of food and limiting

the nicotine and caffeine.

Long Term Goals

 Follow up sessions taken to ensure the efficacy of therapy and to maintain the changes in

behavior.

 Continuation of the short term goals.

 Resolve the core conflict that is the source of anxiety.

Treatment

Techniques Applied

 Rapport Building

 Psycho education

 Vicious Cycle

 Deep Breathing

 16 Progressive Muscle Relaxation (PMR)

 Activity Scheduling

 Anxiety Busting Techniques

 Distraction Techniques

Rapport Building Rapport building is necessary for building strong client-therapist

relationship. In order to build therapeutic bond rapport was built with the client (Dickstein, 2018).

Rapport building was done with the client. In initial sessions client looked anxious and tried to avoid

the session but after sometime she became comfortable. It was difficult to build rapport at the

beginning but later client started talking comfortably with the trainee psychologist. She talked about

her problems and when her problems started. She talked about her mother and cousin who brought
 63

her here. It was made clear to the client that her information will be kept confidential and used only

for educational purpose.

Psycho Education It is the process of providing education and information to those seeking

and receiving mental health services and their family members (Nour, 2014). Client was educated

about her problem. It was told to the client that her anxiousness and worry could be treated. Viscous

cycle was helpful during psycho education. Viscous cycle was shown to the client and told her that

how her worry began and became uncontrollable. She was provided with information regarding

anxiety along with rationale of different techniques which were to be used.

Deep Breathing It was told to the client that when she became anxious or felt restlessness,

she should start deep breathing. Because with the help of deep breathing flow of oxygen increases in

blood. With the help of batter transport of oxygen in blood and brain her restlessness and

anxiousness decreases. Deep breathing is done when person had trouble holding the breath or when

the heart beat accelerated (Brown, 2005). The patient was taught the method of deep breathing to

practice a degree of mastery of her symptoms of anxiety. She was told that she can use deep

breathing for distraction of the anxiety and whenever she felt like her anxiety thermometer start

increasing she could relax herself by using deep breathing. The patient was first ask to take long deep

breath in order to evaluate her by putting one hand at the chest and one hand at the abdomen. After

that she was explained the right method of the breathing that how she supposed to breath. The right

method was demonstrated by the trainee therapist and then she was asked to do deep breathing by

inhaling the oxygen through the nose then holding it for some time and exhale it through mouth. The

patient was advised to deep breath daily for twice a day so that she had enough practice for it to deep

breath before her anxiousness made her upset. In the next few sessions the patient started reporting

that he felt a sense of relaxation while doing deep breathing though it not help her in every setting

but when she felt confused she practiced it and get a relief and it was helpful for sound sleep.
 64

Progressive Muscle Relaxation Technique PMR technique was taught to the client. It was

told to her that how to tense and relaxed different muscles. It was told to her that how to maintain

concentration on one group of muscles and how it will help her during restlessness. Relaxation was

thought to the patient with the basic premise that the tense muscles would be relaxed. The client felt

pain in the body because of muscle fatigue so she was taught that muscle tension somewhat related

to her problem which makes her unable to feel relaxed (Baider, 1994).

The patient was thought 16 muscle relaxations. She was given the detailed description of the

technique. The client was provided with the clear instructions about how she supposed to create

tension in the muscle and then felt relaxed. After explaining the rational of the technique the client

were given demonstration to address the queries regarding muscle tension and relaxation. The client

was asked to practice PMR daily especially when she awakes in the morning. In the first few

sessions for practice the client were did this technique in the start of every session. After 2 sessions

he was asked to practice it alone. The trainee therapist gets the feedback from the client in every

session. The client reported that she felt better after practicing this technique.

Distraction Techniques Distraction techniques were basically used to counter the anxiety

(Sadruddin, 2017). Whenever the client’s mind was occupied with the thoughts began to take hold of

her. The client was suggested to divert her attention by using the list of the activities devised by the

activity scheduling and another method would be used by including the cognitive distractions for

example by counting the lights of the room and backward counting. Talking to someone or by

indulging oneself in relaxing exercise would also help her to overcome the anxious thought. The

client reported that diversion strategies helped her in delaying the worries and the fear that something

awful is going to happen with her.

Activity Scheduling Activity scheduling was done for the client in order to maintain her

daily routine. A chart was made for the client and told her to follow her for the maintenance of her

life. The most suited activity scheduling was devised for the client with her collaboration in order to
 65

carry out daily activities on a schedule and to keep a person busy in healthy tasks (Rupke, 2016).

Focus of the activity scheduling was on the day activities done by the client, practicing the relaxing

techniques thought to the client and to monitor inter personal relations of the client. Activity

scheduling helped her to resume the daily tasks done by the client. After few sessions she was asked

to plan out few tasks for the next day and the reason was to ensure her that she had the ability to plan

and perform the tasks respectively. It helped her to become out of the feelings of being overwhelmed

and also provide her diversion from anxiety provoking thoughts.

Anxiety Busting Techniques A healthy, balanced lifestyle plays a big role in keeping the

symptoms of GAD controlled for the client. In addition to regular exercise and relaxation, by

adapting different other healthy ways in the lifestyle could tackle the chronic anxiety and worry. The

client was asked to take healthy food and to limit the amount of caffeine and nicotine to enter the

body. The client was addicted tea so she was asked to reduce the amount of it for better

gastrointestinal functioning. The client was asked to eat healthy food as she was very much

concerned about his health. Food doesn’t cause anxiety, but a healthy diet can help keep you on an

even keel. Going too long without eating might lead to low blood sugar which can make client feel

anxious and irritable so she was asked to start the day right with breakfast and continue with regular

meals. She was asked to avoid the intake of sodas and other junk food so that he could not have

constipation.

Pre and Post Management Subjective Ratings

Pre and Post Management Subjective Ratings were taken from the client and the purpose

behind it was to compare pre-management and post-management ratings of the problems from client.

Client had rated the problem out of the scale of 0-10. 0 is the minimum problem and 10 means severe

problem.
 66

Table 4

The Pre and Post Rating of The Client’s Problem

Presenting Complaints Pre Assessment Post Assessment

Restlessness 7 5

Palpitations 7 6

Lack of Concentration 8 6

Irritability 8 7

Fatigue 8 6

Social Withdrawal 8 7

Total 46 37

Client’s Pre and Post Management Subjective Ratings of the problem indicate that she had

moderate level of problems and after the management these problems had decrease and improvement

in her symptoms were reported.

Limitations

 The psychological assessment was often interrupted because of the on-going treatment of the

client.

 Separate session room was not available.

 Informant was not available throughout the assessment. Information from family members

could not be collected which could be very helpful in identifying more factors of illness.

Recommendations

 Interview should be conducted in an environment which is free of any distractions or

disturbance.
 67

Session Report

Session 1 (45 minutes)

The goal of the session was to build rapport with client, make behavioral observation and

history taking. Information regarding bio data, family, educational, sexual, marital and history of her

illness was taken from client to help build helpful relationship with client and detailed information

about her. Complete information was gathered after rapport building.

Session 2 (35 minutes)

The goal of the session was to do Psycho-education with the client. Psycho-education was

done with the client to develop the awareness about her problem. To give the insight to client

regarding her illness, nature of problem and other contributing factors. Client understands and

identifies various environmental factors which contributed to these factors. Client understands the

vicious cycle of panic.

Session 3 (40 minutes)

The goal of the session was to do Mental State Examination (MSE) and was assessed through

Generalized Anxiety Disorder Scale (GAD-7). Assessment Scale was applied and questions were

asked to know about her current mental functioning level to know about the severity of client’s

problem. Informal and formal assessment was completed.

Session 4 (35 minutes)

The goal of the session was to tell the client that how to relax herself through deep breathing.

On the other hand, PMR was also taught to client. Deep breathing and PMR was done with client. To

develop the understanding in her that she could relax herself with the help of these techniques. Client

came to know that she could made herself relax when she felt anxious or fatigued.

Session 5 (45 minutes)

The goal of the session was to teach the anxiety busting to the client that how to manage

herself when she felt worried and anxious. On the other hand distracting techniques was also selected
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for the client. Distraction techniques were taught to client. Whenever she felt worry she could easily

distract herself so she could cope with her worry and concentrate on other things. Understanding

about distraction was developed. She came to know that she could deal with her worry.

Session 6 (35 minutes)

To made activity Scheduling chart for the client. Conversation was made with client so that

her daily routine tasks could be maintained. To maintain her daily routine Activity Scheduling Chart

was made for the client.

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References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders (DSM-5). American Psychiatric Association Washington, DC.

Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya Yogic breathing in the treatment of

stress, anxiety, and depression: part II—clinical applications and guidelines. Journal

of Alternative & Complementary Medicine, 11(4), 711-717.

Baider, L., Uziely, B., & De-Nour, A. K. (1994). Progressive muscle relaxation and guided

imagery in cancer patients. General Hospital Psychiatry, 16(5), 340-347.

Dickstein, J. M. (2018). For the Love of Nonhumanity: Anxiety, the Phallus, Transference,

and Algorithmic Criticism. In Lacan and the Nonhuman (pp. 249-276). Palgrave

Macmillan, Cham.

Sadruddin, S., Jan, R., Jabbar, A. A., Nanji, K., & Tharani, A. (2017). Patient education and

mind diversion in supportive care. British Journal of Nursing, 26(10), S14-S19.

Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford,

U.K.: Oxford University Press. p. 202. ISBN 0-19-506251-5.

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Case Summary

The client P.S was 20 years old, student of BSC, unmarried, elder among her 3 siblings. She

was referred with complaints of restlessness, headache, odd talk, sleep problems, and hallucinations.

The client was smiling and talking to herself continuously and was saying odd irrelevant stuff.

Psychological assessment was carried out on informal and formal level which consists of

History Taking, Behavioral Observation, Mental State Examination and Subjective Rating of

Symptoms. Formal assessment was done with the help of Brief Psychiatric Rating Scale (BPRS).

According to the presenting complaints and on the basis of psychological assessment, client was

diagnosed with “Brief Psychotic Disorder” 298.8 (F23), Moderate according to the diagnostic criteria

of DSM-V.

The management plan was devised for the client that included rapport building, psycho

education, deep breathing, distraction techniques and family therapy. The therapies helped her much

in improving her hallucinations and other psychotic symptoms.

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Bio data

Name P.S

Age 20 years

Gender Female

No. of siblings 4 (1 brother, 3 sisters)

Birth order 1st born

Education BSC

Occupation Student

Marital status Unmarried

Religion Islam

No. of sessions 06

Source and Reason of Referral

The client was referred by the psychiatrist to trainee clinical psychologist for the purpose of

psychological assessment and management.

Presenting Complaints

Table 1

Presenting Complaints and Duration of Client’s Problems reported by Informant

Duration Presenting Complaints

‫ایک ہفتہ‬ ‫۔نیند نہیں آتی ہے‬1
‫ایک ہفتہ‬ ‫۔عجیب باتیں کرتی ہے‬2
‫ایک ہفتہ‬ ‫۔خود سے باتیں کرتی ہے‬3
‫پندرہ دن‬ ‫۔بے چینی ہوتی ہے‬4
‫دو سال‬ ‫۔ غصہ آتا ہے‬5
‫دو سال‬ ‫۔سر درد کرتا ہے‬6
‫ایک ہفتہ‬ ‫۔آوزیں سنائی دیتی ہیں چیزیں دکھائی دیتی ہیں‬7
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Initial Observation

At the start of first session client was smiling and talking to herself continuously and was

saying odd irrelevant stuff. The client appeared to be a young girl with slurred speech, disheveled

hair, dressed in shalwar kameez without dupatta, talking odd stuff. She was not answering properly

to all questions.

History of Present Problem

The reason behind the client illness started when the client was in 8 th class (7 years before).

Client had emotional attachment with her class fellow since 8 th grade. She was interested in that boy

but due to some misunderstanding between them they broke up. Since then, the client stalks his face

book ID and having known how about him. But somehow, she continued her studies broken

heartedly and was depressed, irritated and aggressive most of the time.

Now a week ago, informant said that the client locked herself in bathroom and remained

there for hours, open her hair, saying odd things (take name of cousins and said slapped them all),

and showing odd behavior. While talking odd the patient used to smile to herself. The client’s mother

said that she was continually saying that do their Nikah. Then one day the client messaged her lover

to come and meet her and after his visit the illness was triggered. The client’s mother often scolded

her daughter for this kind of attitude. Client also disliked her younger sister as she thought that her

sister told all about her affair to her mother. Now at present the client only remembers her school

friends, and consistently repeating their names. Client has no guilt over her behavior and her main

stressor was her unsuccessful relationship affair. For her above-mentioned problems client was

referred to trainee psychologist for the assessment and management of her problems.

Background Information

Personal History

According to her parents client has normal birth. Her early development is normal. As she

heard from her mother, all mile stones are normally achieved. Client has normal childhood. She has
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never experienced separation from her parents. She starts her religious education when she was 5

years old. She belongs to a middle-class family and has a good relation with society. In her leisure

time she watched videos on YouTube and listened music.

Family History

Client lived in joint family system. She belonged to middle class family. Client’s home

environment was not so calm and all the members of family were not so happy. Clients face some

kind of family crisis because she lived in joint family system. Client’s father was a policeman by

profession, 45 years old. He had cold temperament and the client’s relationship towards her was non

congenial and distant. Client’s mother was 40 years old and was a housewife. She had good

relationship with client. The client has one younger brother. He also had distant relationship with her.

Client has two younger sisters. Not having a friendly relationship among them. They often quarrel

with client on very small things.

Educational History

He started his school at the age of 5 years. His physical health was good. She was an average

student and done BSC with average grades.

Sexual History

The client was single unmarried girl. No sexual issues, having regular menstruation cycles

with normal blood loss.

Pre morbid Personality

The client has extrovert personality. Have friendly relations with family and friends. The

client offered prayer regularly and recited Holy Quran daily. She was a cheerful person. Her reaction

towards stress was in very quiet manner till things got better.

History of Medical Illness

The client did not have any history of psychiatric or medical illness in her family. Her birth

was also normal and milestones were appropriate. According to the informant the client was normal
 74

in her childhood and no one in her family has this type of illness. So, this gives assurance that there

was no sign of any family medical illness record.

Assessment

Informal Assessment

 History Taking

 Behavioral Observation

 Mental State Examination

 Subjective Rating of Symptoms

Formal Assessment

 Brief Psychiatric Rating Scale

Informal Assessment

History Taking. History was taken in two sessions. Informant was her mother. In history,

past and present problem history, medical, psychiatric history, sexual history, home environment,

school and college period, early development was included.

Behavioral Observation. At the start of first session the client was looking very upset, she

had poor eye contact, slurred speech, disheveled hair, dressed in shalwar kameez without dupatta,

talking odd stuff. She was not answering properly to all questions.

Mental Status Examination (MSE). MSE is a useful diagnostic tool in psychiatric practice.

It is a semi structured method for describing the clients mental state and behaviors at a given

moment. Diagnostic and therapeutic decisions about client are based on the findings of MSE

(Trzepacz & Baker, 1993)

Appearance. The client P.S appeared to be a young girl with slurred speech, disheveled hair,

dressed in shalwar kameez without dupatta and talking odd stuff. Her weight was 60 kg. Her

apparent age was similar to her chronological age.

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Attitude. Her attitude was not much cooperative. She was not answering properly to all

questions. She was having very low of eye contact. She was watching here and there and gazing at

the wall. When she entered in the room, her eyes were not static and she was watching here and

there.

Behavior. She was not showing any psychomotor agitation.

Speech. She had low rate and volume of speech, she could not speak properly and was not

able to convey her message.

Mood. The client had low mood throughout the interview.

Thought Process. She had disturbed, confused and disrupted patterns of thoughts.

Thought Content. There were signs of suicidal ideation.

Orientation. She did not know time. She did not know what place was that where she was

sitting. She knew the names of family members. She can recognize every one very simply.

Perception. Her perception, attention and concentration were not appropriate. Client

reported auditory and visual hallucinations.

Memory and Concentration. She could remember many things but she was so confused and

forgetting very little detail. She did not have memory issues. Her short term, long term and remote

memory were intact.

General Information/Intelligence. He may had general knowledge about things. But she did

not replied to all question asked simply from his daily life.

Insight. Insight was not present at that time.

Subjective Rating. The client was asked to rate the problem from the range of “0-10” rating

scale in which the score lies above 5 would indicate the severity of the problem while the score lie

below the 5 would indicate the less severity or absence of the symptoms.
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Table 2

Subjective Rating of the Problems by Client (Pre-assessment)

Presenting Complaints Rating

Odd talk 10

Difficulty in sleep 9

Restlessness 9

Anger 9

Self-talk 10

Headache 9

Hallucinations 9

Formal Assessment

Brief Psychiatric Rating Scale (Overall et al., 1962). It is 18- item scale used widely to assess the

effectiveness of treatment. The BPRS is rating scale clinician or researcher use to measure

psychiatric symptoms such as anxiety, depression, hallucinations, psychosis and unusual behavior.

The rater enters a number for each symptom construct that ranges from 1 (not present) to 7

(extremely severe).

Table 2

Table Showing Scores Obtained in Brief Psychiatric Rating Scale

Raw scores Range Severity level

29 21-30 Moderate

Interpretation. The total scores of the client on BPRS were 29 that showed she was moderately

psychotic. Those items included the results showed that she had auditory and visual hallucinations,
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poor attention, blunted affect, unusual thought concern and emotional withdrawal. The results of that

tool showed that the client was suffering from the Brief Psychotic Disorder, Moderate.

Diagnosis

According to DSM-5 the client was suffering from “Brief Psychotic Disorder” 298.8(F23),

Moderate.

Client’s Prognosis

The client initially was not cooperative with trainee psychologist but latterly she got insight

of her psychological problem. With counseling and medicine, she can be back to her normal life;

overall, the prognosis was good.

Intervention Plan

Short Term Goals

 Developing the therapeutic alliance with the client and motivating the client to indulge in the

therapy for treatment.

 Psycho education was done to make her family to understand about the disorder.

 Tell her to take proper drugs and follow doctor’s advice.

 Council her family as well.

 Deep Breathing was taught to client as a strategy for general stress reduction.

Long Term Goals

 Continuation of short term goals.

 To enhance functional life of the client

 Stabilize the client and enable her to deal effectively the traumatic events.

 Follow up sessions would be conducted.

Treatment

Techniques Applied

 Rapport Building
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 Psycho education

 Deep Breathing

 Family Therapy

 Thought Distraction Techniques

Rapport Building. Rapport building is necessary for building strong client-therapist

relationship. In order to build therapeutic bond rapport was built with the client (Dickstein, 2018).

Rapport building was done with the client. In initial sessions client tried to avoid the session but after

sometime she became comfortable. It was difficult to build rapport at the beginning but later client

started talking comfortably with the trainee psychologist. She talked about her problems. It was made

clear to the client that her information will be kept confidential.

Psycho Education. Psycho education is of deem importance starting psychological treatment

of Depression as well as other disorders. Education provides a knowledge base that gives the

individual greater control over the disorder (De-Nour, 2014).

Psycho-education refers to the education offered to people who live with a psychological

disturbance. It consists of giving clients and their relative’s adequate knowledge about disorder and

teaching illness self-management skills so that people have a better understanding of their illness and

its treatment. Client and her family are educated. Awareness about disorder, early detection of

warning symptoms and adherence with treatment is given to client’s family.

Deep Breathing. It was told to the client that when she became anxious or felt restlessness,

she should start deep breathing. Because with the help of deep breathing flow of oxygen increases in

blood. With the help of batter transport of oxygen in blood and brain her restlessness and

anxiousness decreases. Deep breathing is done when a person had trouble holding the breath or when

the heartbeat accelerated (Brown, 2005).

The patient was taught the method of deep breathing to practice a degree of mastery of her

symptoms of anxiety. She was told that she can use deep breathing for distraction of the anxiety and
 79

whenever she felt like her anxiety thermometer start increasing, she could relax herself by using deep

breathing. The patient was first asked to take long deep breath in order to evaluate her by putting one

hand at the chest and one hand at the abdomen. After that she was explained the right method of the

breathing that how she supposed to breath. The right method was demonstrated by the trainee

therapist and then she was asked to do deep breathing by inhaling the oxygen through the nose then

holding it for some time and exhale it through mouth. The patient was advised to deep breath daily

for twice a day so that she had enough practice for it to deep breath before her anxiousness made her

upset. In the next few sessions, the patient started reporting that he felt a sense of relaxation while

doing deep breathing though it not helps her in every setting but when she felt confused, she

practiced it and get a relief and it was helpful for sound sleep.

Family Therapy. Family therapy is based on the idea that the problem of the family

influences each member and that the problem of each member influence the family. As such, family

therapy is used to address specific symptoms of given family member. Some therapist also asked the

questions about whether parents assume an appropriate level of responsibility. For it may be to

improve communication, to change roles or to address a range of family problems. In family therapy,

relatives develop more realistic expectations and become more tolerant, less guilt-ridden, and more

willing to try new patterns of communication. Family therapy also helps the person with

schizophrenia cope with the pressures of family life, make better use of family members, and avoid

troublesome interactions (Minuchin, 1960)

Thought Distraction Technique. Using distraction techniques helps in many ways. Most

importantly, distracting ourselves can help to keep us safe and avoid harming ourselves.

Additionally, by successfully and continually distracting ourselves, we eventually learn to trust our

own ability to cope with difficult emotions and situations. Then, as we store up evidence of our

ability to cope, we in turn also strengthen our resilience. Ultimately, over time as we hone the skill of
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distraction, we develop better habits for taking care of our mental health. It was helpful for client to

deal with her delusions and visual hallucination that are causing problem for her (Finley, 2005)

Pre and Post Management Subjective Ratings

Pre and Post Management Subjective Ratings were taken from the client and compare pre and

post-management ratings of the problems from client. Client had rated the problem out of the scale

of 0-10. 0 is the minimum problem and 10 means severe problem.

Table 4

The Pre and Post Rating of The Client’s Problem

Presenting Complaints Pre-Assessment Post Assessment

Odd talk 10 8

Difficulty in sleep 9 6

Restlessness 9 7

Anger 9 7

Self-talk 10 8

Headache 9 7

Hallucinations 9 7

Total 65 50

According to the post assessment it was revealed that client’s symptoms severity decreases

after the application of different techniques included in management plan.

Limitations

 Separate session room was not available.

 There was no sound proof atmosphere for the relaxation exercise

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Recommendations

 The client should come for the follow up sessions for the further management of her

problems to cope fully with her psychotic symptoms.

 Interview should be conducted in an environment that is free of any distractions or

disturbance
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Session Report

1st Session (35 minutes)

In the first session the presenting complaints of the client were obtain by her informant as

well as initial observation was noted. Client interview was conducted. To obtained the details history

regarding the problems of the client including the history of present illness, personal history and

family history. The report was also started to build with the client gained trust and rapport was built.

2nd Session (40 minutes)

The second session was conducted to be known about her general information, medical status

and employment status. Psycho education was provided to the client and his family about illness,

treatment, clinical course and prognosis.

3rd Session (35 minutes)

The goal of the session was to do Mental State Examination (MSE). Questions were asked to

know about his current mental functioning level and to know about the severity of the client’s

problem. Informal Assessment was completed.

4th Session (40 minutes)

The goal of the session was to apply BPRS on the client to know about the severity level of

illness and tell the client that how to relax himself through deep breathing. On the other hand,

distraction techniques were also taught to client. Deep breathing was done with client. To develop

the understanding in him that she could relax herself with the help of these techniques. The client

came to know that she could make herself relax when she felt tensed or fatigue.

5th Session (35 minutes)

The goal of the session was to do Family Therapy. The goal of Family Therapy is to help

family members improve communication, solve family problems, understand and handle special

family situations and create a better functioning home environment.

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6th Session (30 minutes)

The goal of the session was to take feedback from the client. Conversation was made with

client so that her daily routine tasks could be maintained.

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References

American Psychological Association (2010). Manual of the American Psychological

Association (6th ed.). Washington, DC: Author Press.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders (4th ed.). Washington, DC: Author Press.

Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya Yogic breathing in the treatment of

stress, anxiety, and depression: part II—clinical applications and guidelines. Journal

of Alternative & Complementary Medicine, 11(4), 711-717.

Burstein, M., & Ginsburg, G. S. (2010). The effect of parental modeling of anxious

behaviors and cognitions in school-aged children: An experimental pilot study.

Behaviour research and therapy, 48(6), 506-515.

Baider, L., Uziely, B., & De-Nour, A. K. (1994). Progressive muscle relaxation and guided

imagery in cancer patients. General Hospital Psychiatry, 16(5), 340-347.

Dickstein, J. M. (2018). For the Love of Nonhumanity: Anxiety, the Phallus, Transference,

and Algorithmic Criticism. In Lacan and the Nonhuman (pp. 249-276). Palgrave

Macmillan, Cham.

Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J.

(1995). The structure of the genetic and environmental risk factors for six major

psychiatric disorders in women: Phobia, generalized anxiety disorder, panic

disorder, bulimia, major depression, and alcoholism. Archives of general psychiatry,

52(5), 374-383.

Sadruddin, S., Jan, R., Jabbar, A. A., Nanji, K., & Tharani, A. (2017). Patient education and

mind diversion in supportive care. British Journal of Nursing, 26(10), S14-S19