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CLINICAL CASE REPORTS

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Case: 1

Total sessions: 8

Persistent Depressive Disorder

Depression is a common and serious medical illness that negatively affects how you feel, the
way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of
sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional
and physical problems and can decrease a person’s ability to function at work and at home.

Agency/Setting

The case was taken from Fauji Foundation Hospital, Rawalpindi.

Background of Client/ Demographic detail

Name: Mrs. S

Age: 42 years

Gender: Female

Education: Grade 4

Marital Status: Married

Occupation: Housewife

Residence: Tarnol

Spouse age: 46

Education: Matriculation

Spouse Orientation: Taxi Driver

No of children: 4

Source of referral

Client was recommended to visit/see a psychologist by her niece.

Presenting Complaints
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“Niend nahi aati sari rat, kisi se bat krne ko dil nahi karta mera, bhook nahi lgti aur lag jaye tou
kuch khane ko dil nahi krta, himat nahi hoti ab kaam krne ki, rona ata rehta hai, pata nahi ye sab
halaat thek hongy ya nahi, zindagi bht achi thi magar mian ki tawajo hatne k bad pareshan rhne
lgi hon.”

History of Present Illness

Client’s problem started 2 years ago, because of some stressful events that occurred in her life.
2.5 years ago she got her daughter married to a person who was financially stable, the client said
that the other two sons in law were not financially well so she wanted this daughter to have a
good life. She reported that on the day of marriage some people told her and her family that their
son in law was already married and had kids but they didn’t believe it. Her daughter was living
in a farm house with her husband and after four months his first wife came to the farm house
along with her children. The client reported that her son in laws first wife was rich and had
resources, she forced the client’s daughter to go back home and keep no contact with her
husband. Her husband didn’t take a stand for her and said that he would divorce her and set her
free if she wanted. This event was distressing for the client. She reported that her husband had
held her responsible for this event and said that he wasn’t in favor of this marriage in the first
place. Alongside this, the client said that 15 days following this event her daughter in law started
demanding a separate house by saying she couldn’t live in this house because of the client’s
daughter who came back home. This created another frustration in the house and after a week the
client’s son and daughter in law shifted to a house near their house, against the client’s will.
Client reported that she was very attached to her son and this shifting was very painful for her.
She said she tried to make things better but she gave up eventually. Her husband had stopped
talking to her, her son shifted to another house, her daughter was to be divorced, and these events
ultimately resulted in client’s low mood most of the time, hopeless thoughts, and loss of interest
in activities, disturbed sleep and appetite. She reported that her husband had always supported
her in 28 years of their marriage, gave her attention and importance but this change in his
behavior adversely affected her.

Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History

No significant past medical history was reported.

Family history
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Mrs. S.B was a housewife and belonged to a middle class family, she was 42 years old. She lived
in a nuclear family. Her parents were deceased. She had two brothers and one sister, all her
siblings were married and she reported to have good relation with them. Her husband was 46
years old and was a taxi driver by profession, she has had good relationship with him but since
the last 1.5 years her relation with him was disturbed. She had 1 son and 3 daughters, all her
children were married. There was no family history of psychological disorder.

Personal History

Client’s birth was normal and without any complications, she achieved all milestones on time.
She received education up to grade 4 because her parents couldn’t afford it but she expressed that
she really wanted to study more when she was young. She got married at the age of 13. She
reported that her father and her parents in law were strict but her husband was a loving person
and supported her a lot in every matter.

Premorbid Personality

Mrs. S.B was very friendly, talkative and social and she used to take good care of her children
and family before the onset of the symptoms of dysthymia.

Mental Status Examination (MSE)/ Observation

A middle age 42 years old female who was well dressed, was neat and clean in appearance.
Client was well oriented about time, place and setting and had insight about her problem and
openly discussed the problems. She was cooperative, attentive and had a soft tone during the
session. No formal thought disorder was found.

Diagnosis

300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)

Case Conceptualization/ Theoretical Orientation

According to Beck’s cognitive model of depression, depressive disorders are characterized by

people's dysfunctional negative views of themselves, their life experience (and the world in
general), and their future—the cognitive triad. People with depression often view themselves as
unlovable, helpless, doomed or deficient. They tend to attribute their unpleasant experiences to
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their presumed physical, mental, and/or moral deficits. They may have a very difficult time
viewing themselves as people who could ever succeed, be accepted, or feel good about
themselves and this may lead to withdrawal and isolation, which further worsens the mood.
(Beck, A. T. 1979)

Similarly in the client’s case, after the stressful events she started avoiding people as she started
thinking negatively that they were not good and came just to make fun of her misery and thus
isolated herself from everything, lost interest in activities she was indulged in, before the onset of
symptoms.

Progression of Therapy (No. of sessions)

Eight sessions were conducted

Session I:
The first session was of 40 minutes. Client was willing to improve her condition and was open
about the problems she was facing, so rapport was built easily. In this session client’s
demographic details were taken, presenting complaints and the causes that led to the presenting
complaints were explored. While talking about the precipitating event the client started crying as
she was very disturbed by the events and was having difficulty in accepting and moving on. An
empathetic, inquiring and respectful stance was maintained, relaxation exercise was used to
make the client relaxed.

Session II:

During second session detailed family and personal history was taken. She reported that her
parents and parents in law were strict and that her husband always took care of her and supported
her in everything and gave her a lot of attention. Now that he stopped talking to her, this affected
her adversely. On probing, she told that she also didn’t make any efforts to talk to her husband or
resolve the problem. Client also complained that her son changed after his marriage, when
probed on this area, she admitted and realized that he was actually taking care of her the same
way he used to take care of her before marriage and said that she was feeling too much and
didn’t understand that her son had more responsibilities now.

HTP and BDI were also administered in this session.

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Session III:

Session 3 started by summarizing the previous session. In this session RISB and BGT were
administered on the client.

An activity chart was also made for the client with the client’s consent. As the client didn’t feel
like doing anything or talking to anyone so an activity chart was made to indulge the client in
activities. Activity chart included activities including household chores, spending time with her
family, making and drinking tea with her husband as a way of improving their relation. The
client was motivated to follow the activity chart.

Session IV:

In this session, the client reported that she was feeling better as she followed the activity chart
and kept herself busy. Although she said she was having difficulty to follow it initially. She also
reported that she drank tea together with her husband after a long time and it made her feel good.
Standard progressive matrix (SPM) was administered which indicated that the client was
intellectually average.

Session V:

In session 5 TAT was administered, only those cards were administered which were relevant to
the client’s problem.

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken. The client was suggested that her husband had previously provided important support
to her and that a dispute had significantly contributed to her despair and isolation. The client was
given rationalization and importance of therapy in resolving her problem.

Session VI:

Interpersonal therapy was used to improve client’s personal relationship and to indulge her in
social activities which she had started to avoid because of her symptoms. This session focused on
both, client’s personal relationships and involvement in social activities (meeting a relative or
neighbors) or go shopping etc. The relation that she wanted to work on or bring change to was
her relation with her husband. She was asked what she wanted or expected from her husband and
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what goals did she want to set for improving the relationship. The client wanted her husband’s
care, attention, support, she said she would cook his favorite food, make breakfast for him and
have breakfast together. She was motivated to talk to her husband as well apart from doing the
chores, as a next step.

The client was asked to bring her husband in the next session for couple therapy.

Session VII:

In session 7, client came with a relaxed and happy mood she said she was excited to talk about
the shopping she did for her grandson who was born last week. She reported that she went out
after a really long time and it wasn’t as bad as she had imagined it, it felt good to be out for a
while and that she enjoyed it. She also stated that her husband was happy when she made his
favorite dinner, had a little conversation as well.

An individual session was then conducted with her husband, he claimed that his wife had started
talking about the past mistakes and that she had started worrying too much, talked about
problems that were going in the neighbors lives when he was at home. He said he tried to talk
about it and advised her to let go of what had happened but it used to turn into a fight so he then
stayed away and avoided talking to her in order to avoid the fight. He was asked what he wanted
from his relation with his wife, he wanted her to be happy, live in the present and avoid talking
about others and their problems as he didn’t like to hear about it after a hectic routine. He was
given an insight that the change he brought in his behavior to avoid the fight actually turned out
to be something more adverse and affected her wife.

Couple therapy was conducted on the same day in the same session because her husband was a
taxi driver and couldn’t afford holidays. Both of them discussed the conflicts and expectations in
the session and came to a mutual understanding. They were also asked about their plans for their
daughter, the client’s husband said that he is looking forward to finding someone trustworthy for
marriage. They were then suggested and motivated to get their daughter to do a job, she wasn’t
much educated and couldn’t get a job with good income but they stated that their daughter
expressed that she wanted to work in a parlor. Their opinion and consent was taken and asked if
they had any objections, both the client and her husband understood the importance of the job
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and said that they would allow their daughter to do whatever she wants to do regarding the job
and marriage.

Session VIII:

In this session client’s feedback was taken, she was satisfied and feeling much better after the
last session’s couple therapy as misunderstandings were cleared. She said that her husband did
initiate conversation and spent time with her this weekend and she also stated that she didn’t talk
or mention anything from the past as was discussed in the couple therapy. She said that thoughts
about the past still do bother her but she was positive that she would get over it and focus on
what is important in the present and keep her family together. She said that she learnt from the
therapy sessions that things do work out, importance of talking and that sometimes we have to
take the first step to remove distances and the importance of living in the present and learning.
The client was reinforced and appreciated for being active and following the therapy and was
motivated that she could cope with future difficulties and conflicts.

The session was terminated with the mutual consent of the both the client and the therapist. She
was also told to take follow ups in future if needed.

Assessments

Evaluative Techniques/ Interpretation

1. House Tree Person (HTP)

2. Beck Depression Inventory (BDI)
3. Rotter Incomplete Sentence Blank (RISB)
4. Raven Standard Progressive Matrix (RSPM)
5. Bender Gestalt Test (BGT)
6. Thematic Apperception Test (TAT)

House Tree Person (HTP)

The HTP of the client depicts environmental pressure, insecurity feelings, poor interpersonal
relationships and lack of warmth in family, feelings of discouragement and guilt. It also indicated
that conflicts, strong attachment or dependency over the opposite gender as the opposite gender
was drawn first.
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Beck Depression Inventory

Client scored 33 on BDI which indicated severe depression.

Rotter Incomplete Sentence Blank

Client scored 126 on RISB which indicates that the client was socially adjusted as the score was
below the cutoff score that is 135. The results showed that the problem was in personal domain.

Raven Standard Progressive Matrix

Client acquired a score of 37 and grade III that fell under 50th percentile which indicated that the
client was intellectually average.

Bender Gestalt Test

Client scored 0 on BGT which indicated an absence of visuoconstructive deficits or brain

impairments.

Thematic Apperception Test

TAT revealed that client was disturbed because of her husband and wanted his care and
attention. The client’s stories were adequate to the client’s problem, her stories also revealed that
she had some hope that things would get better. Client had an unsupportive family environment
as revealed by her stories. The interpretation of TAT indicated the need for affiliation,
succorance, autonomy and passivity.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis of the client was moderately favorable as the client was cooperative and actively
participating in the sessions.
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Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to deal with her problems efficiently. She was also told to take follow ups in
future if needed.
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References

Beck, Aaron, T (1979). Cognitive Therapy of Depression. New York: The Guilford Press.
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APPENDIX
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Case: 2

Total Sessions: 9

Social Anxiety Disorder

The defining feature of social anxiety disorder, also called social phobia, is intense anxiety or
fear of being judged, negatively evaluated, or rejected in a social or performance situation.
People with social anxiety disorder may worry about acting or appearing visibly anxious (e.g.,
blushing, stumbling over words), or being viewed as stupid, awkward, or boring.

Agency/Setting

The case was taken from Fauji Foundation Hospital, Rawalpindi.

Background of Client/ Demographic detail

Name: Ms. K
Age: 19 years
Gender: Female
Birth Order: Second born
Education: BS Engineering
Marital Status: Single
Residence: Islamabad

Source of referral

Client was brought to the hospital by her sister

Presenting Complaints

“Main class mei presentations nahi de paa rahi, na hi class discussions mei participate kr pati
hon, sab phir se hasengy mujh pe isliye main presentation walay din jaati hi nahi but mere grades
bhi kharab horhe hain attendance bhi affect horhi hai. Main kaise don presentations, soch kar hi
ajeeb halat hojati hai”
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History of Present Illness

Client’s problem started 7 months ago when she gave presentation of one subject in the first
semester, she reported that she had prepared well for the presentation and also was excited for it
bur during the presentation she made a few mistakes on which her class started laughing at her
and after which she forgot the rest of her presentation. Her subject teacher was strict and scolded
her for the mistakes. Client reported that she felt humiliated and started crying after the
presentation. Since then the client didn’t give presentations of other subjects, she started skipping
the classes in which presentations were scheduled and also started avoiding class discussions
even if she knew the answer to some question she said she was afraid to answer and feared that
she would be humiliated again. She skipped the rest of her presentations of first semester and had
skipped two presentations of the second semester as well. She said that she had tried to give the
presentations and she did prepare for the presentations but when she thought of standing on the
stage and giving the presentation, her heart beat started to race, she started to sweat, her hands
started to tremble and she felt as if she would faint. She reported that she then started to skip
those particular classes in order to avoid the embarrassment but at the same time she said that her
grades and attendance was being affected and she wanted to get over her fear of giving
presentations and participating in discussions. She also reported that she used to participate in
debates in her college and school and she got first prize an sometimes second but she was always
good at it and wanted to become that confident again but she was unable to get over it.

Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History

No significant past medical history was reported.

Family history

Ms. K was living in a nuclear family and belonged to a middle class family. She was living in
Islamabad. Both her parents were alive, she had two sisters. She reported to have good and
healthy relation with them she was more close to her elder sister and shared everything with her
without hesitation. There was no family history of psychological disorder.
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Personal History

Ms. K was 19 years old and was doing BS Engineering. Client’s birth was normal without any
complications and she achieved all milestones on time as reported by her sister. Her school and
college life went smooth and she was a brilliant student of her class. She also took keen interest
in debates and won competitions. Her performance in university got disturbed because of her
phobia.

Premorbid Personality

Ms. K was confident and fun loving. She used to enjoy participating in debates and attending
university regularly but she had started skipping it because of the presentations. She was friendly
and patient but became a bit irritated and annoyed with her friends whenever they asked her
about her reason of skipping the class.

Mental Status Examination (MSE)/ Observation

A young aged 19 year old girl who was neat and clean in appearance. Client was well oriented
about time, place and setting and had insight about her problem and openly discussed the
problems. She was cooperative, attentive and had a soft tone during the session. No formal
thought disorder was found.

Diagnosis

300.23 (F40.10) Social Anxiety Disorder (Social Phobia), Performance only

Case Conceptualization/ Theoretical Orientation

According to Rachman’s pathways to fear development, direct conditioning of fear typically

involves the experience of being hurt or frightened by the phobic situation or object. Examples
include being humiliated in front of a group, being involved in an automobile accident, falling or
almost falling from a high place. (Rachman, S.J. 1978).

Similarly the client was humiliated and embarrassed in front of her class due to which she had
developed stage fear and started to avoid giving presentations because of anxiety symptoms
associated with the phobia/phobic situation.
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Progression of Therapy (No. of sessions)

Nine sessions were conducted with the client.

Session I:

The first session was of 40 minutes. In this session presenting complaints and the causes of those
complaints were taken, demographics were also taken in this session. Rapport was built in this
session, the client was first reluctant to talk about what was bothering her but during the
interview as rapport was being established, she talked about her problem. An empathetic,
inquiring and respectful stance was maintained.

Session II:

During second session personal and family history was taken from the client. BAI and HTP were
also conducted with the client in this session.

Session III:

In the third session RISB and BGT and SPIN were conducted with the client which indicated that
the client is not neurologically impaired.

Session IV:

In this session SPM was administered on the client, she took 40 minutes to complete the test.

Session V:

In this session TAT was administered on the client, only those cards were used which were
relevant to the client’s problem.

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken.

Session VI:

In this session Reframing Overgeneralization technique was used to help the client identify
negative unhelpful thoughts and replace them with more positive empowering thoughts.
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Counseling was also done which helped the client in understanding that just because something
happened once doesn’t mean it will always happen in the same way.

In this session PMR was practiced with the client and the client was told to repeat the steps when
her anxiety symptoms arise. Deep breathing was also explained and practiced with the client and
was told to practice it before going on the stage to present.

Session VII:

In this session The Mirror Technique was used, it is a confidence building technique. The client
was told to stand in front of the mirror with her head up and shoulders back, look into her eyes,
perform the deep breathing exercise and then start repeating powerful affirmations out loud. She
was told to repeat this twice a day. She was also told to practice presenting in front of the mirror
and keep those affirmations in her mind while she practiced.

Session VIII:

In this session facing your fears, Exposure therapy was used. By practicing The Mirror
Technique in the previous session the client felt confident of herself and in this session she was
told to take the next step using Exposure therapy. In this the client was first told to present in
front of her siblings and parents while practicing deep breathing and positive affirmations as
learnt in the previous sessions. Then perform in front of her friends and then prepare for the
actual class presentation. The client was hesitating at first she was then motivated and
appreciated of her great work and performance in practicing the mirror technique successfully
after which the client decided to follow the steps of exposure therapy.

Session IX

In this session the client reported that she had followed the steps and performed in front of her
family and she was having the anxiety symptoms but she used those affirmations and deep
breathing exercise to calm herself and she reported that she actually performed well. She
practiced twice in front of her family and she felt good about it. She also reported that she even
performed in front of her close friend and her symptoms were lesser this time and she was
confident now. She said that her presentations were going to start after two weeks and that she
would be able to present now, she was still a bit scared but confident at the same time.
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The session was then terminated with the mutual consent of the both the client and the therapist.
Client was appreciated for being cooperative and active in the therapy sessions. Client was
motivated that she could and had the ability to cope with future difficulties and was also told to
take follow ups if needed.

Assessments

Evaluative Techniques/ Interpretation

1. House Tree Person (HTP)

2. Beck Anxiety Inventory (BAI)
3. Rotter Incomplete Sentence Blank (RISB)
4. Social Phobia Inventory (SPIN)
5. Raven Standard Progressive Matrix (RSPM)
6. Bender Gestalt Test (BGT)
7. Thematic Apperception Test (TAT)

House Tree Person (HTP)

The HTP of the client indicated anxiety, inadequacy, indecision, sense of insecurity and confused
thinking. It also indicated discouragement, introversion, dependency and external aggression.

Beck Anxiety Inventory (BAI)

Client scored 31 on BAI which indicated that the client had severe anxiety.

Rotter Incomplete Sentence Blank (RISB)

Client scored 128 on RISB which indicated that the client was socially adjusted as the score was
below the cut off score that is 135. The results showed that the problem was in personal domain.

Social Phobia Inventory (SPIN)

Client scored 25 on social phobia inventory which indicated mild social anxiety

Raven Standard Progressive Matrix (RSPM)

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Client acquired a score of 43 and grade III that fell under 50th percentile which indicated that the
client was intellectually average.

Bender Gestalt Test (BGT)

Client scored 0 on BGT which indicated that the client was not neurologically impaired.

Thematic Apperception Test (TAT)

The stories of the client were adequate to the client’s problem. The interpretation of client’s TAT
stories indicated need for achievement, autonomy and succorance. The stories also indicated lack
of human support, rejection and loss.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis of the client was moderately favorable as the client was cooperative and actively
participating in the sessions.

Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to manage and deal with her problems efficiently. She was also told to take
follow ups in future if needed.
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References

Rachman, S.J. (1978). Fear and Courage. San Francisco: WH Freeman & Co.
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APPENDIX
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Case: 3

Total sessions: 8

Major Depressive Disorder

Depression is a common and serious medical illness that negatively affects how you feel, the
way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of
sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional
and physical problems and can decrease a person’s ability to function at work and at home.

Agency/Setting

The case was taken from Fauji Foundation Hospital, Rawalpindi.

Background of Client/ Demographic detail

Name: Mr. A

Age: 21 years

Gender: Male

Birth Order First born

Education: BS Engineering

Marital Status: Single

Occupation: Tutor

Residence: Islamabad

Source of referral

Client was brought to the hospital by his mother.

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Presenting Complaints

According to client’s mother:

Pata nahi kia hogya hai isy, aik maheene se na kuch kha pee raha hai, na kisi se bat kr rha, udas
bheta rehta hai, pehle aisa nahi tha bohat acha bacha tha, ghar isi ne chalana hai ab, aisa raha toh
kaise chalega sb.”

According to the client:

“Zindagi ajeeb si hogai hai, niend kho bheta hon, pareshan rhne laga hon, har chez se dil uth sa
gaya hai na khana khane ko dil karta hai, dihan se parha nahi paa raha thaka thaka mehsoos karta
hon, samjh nai arha kia kroon, shaid ami sahi hi kehti hain main kisi kaam ka nahi, kuch nahi kar
skta, kisi se keh nahi paa raha tha ye sb, dil hee nai kar rha tha bat krneko kisi se”

History of Present Illness

Client’s problem started one month ago, two months ago his father had a bike accident in which
he had several serious injuries, a serious injury on the head lead his father to coma. This incident
was very distressing for the client. Client reported that life was so good one month ago but it
took a twist and changed everything, his father was healthy but now he was lying helplessly on
the hospital bed. He was also worried about his family as he was the eldest among his siblings
and the only bread maker after his father, he was worried about how he would run the house, pay
his and his siblings institution fee and fulfill other needs of life just by himself. He informed that
he was already taking home tuitions and looking for a job side by side, he was stressed yet was
working hard to fulfill his responsibilities but his mother was not satisfied and happy with him
and told him that he wasn’t hard enough, he doesn’t care about his family and their current
situation and is not making enough financial contributions. He reported that he was trying his
best but his mother didn’t notice or appreciate that instead she kept saying harsh things everyday
due to which the client started losing sleep, had low mood, lost interest in activities, started
feeling worthless, difficulty concentrating and fatigue. He also reported that his mother was
never like this, she never treated him harshly but after his father was hospitalized, she had been
behaving differently.
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Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History

No significant past medical history was reported.

Family history

Mr. A was a student of BS Engineering and belonged to a middle class family, he was 21 years
old and was giving home tuition. He was living in a nuclear family. His parents were alive but
his father was in comma since the past one month, he was more attached to his father. He had
normal relation with his mother. He had two siblings, one sister and one brother, he was the
eldest among the siblings and had a good loving relation with them.

Personal History

Client’s birth was normal and without any complications, he achieved all milestones on time. He
started school at the age of 4, he was a good student in school, college and in university as well.
He had friends and reported that he was good in making friends, he had good relation with all his
friends but currently was out of touch with them as he was stressed. Client had no drug history.

Premorbid Personality

Mr. A was lively, optimistic, friendly and social before the onset of his symptoms. He used to
play basketball with his friends and listen to music in his leisure time. He was active and
energetic before the onset of his symptoms

Mental Status Examination (MSE)/ Observation

A young gentleman of average height and medium built, he had a neat and clean appearance. He
had an audible volume and relevant speech. Client was well oriented about time, place and
person, his memory was intact and he was attentive during the session.

Diagnosis

296.23 (F32.2) Major Depressive Disorder

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Case Conceptualization/ Theoretical Orientation

According to Beck’s cognitive model of depression, depression prone individuals develop

a negative self-schema. They possess a set of beliefs and expectations about themselves that are
essentially negative and pessimistic. Experiences that might contribute to negative schemas
include parental rejection, criticism, overprotection, neglect or abuse. Once the negative schema
are activated a number of illogical thoughts or cognitive biases seem to dominate thinking.
People with negative self-schemas become prone to making logical errors in their thinking and
they tend to focus selectively on certain aspects of a situation while ignoring equally relevant
information. (Beck, A. T. 1983)

Similar was the case with Mr. A, he started developing negative schemas after his mother started
criticizing him and being too hard on him. Due to those negative self-schemas, it was hard for
him to interpret the situation logically that his mother never treated him the way she had started
treating him after his father’s accident and that she was also frustrated and worried about his
father and their current financial issues.

Progression of Therapy (No. of sessions)

Eight sessions were conducted with the client.

Session I:

The first session was of 30 minutes. In this session rapport was built, the client was resistant and
seemed confused about whether or not to talk about what was bothering him. Rapport was built
by talking about his daily routine, his likes and dislikes. Client was assured that his information
and whatever will be discussed in the session would be kept confidential and would not be
shared with anyone without his consent. Demographics were also taken in this session.

Session II:
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In the second session the client was willing to talk about his problem. Presenting complaints and
the causes that led to the presenting complaints were explored. Detailed family and personal
history was taken in this session. Client reported that sudden accident of his father that led to
coma was like a nightmare for him, he tried really hard to keep himself together and focus on his
responsibilities but his mother’s changed behavior towards him and unemployment all together
led him to his present condition. An empathetic, inquiring and respectful stance was maintained,
relaxation exercise was used to make the client relaxed.

BDI was also administered on the client in this session.

Session III:

In this session HTP and RISB were administered on the client.

An activity chart was also made for the client with the client’s consent. As the client didn’t feel
like doing anything or talking to anyone so an activity chart was made to indulge the client in
activities. Rationale for the activity chart was given to the client after which he was willing to
follow it.

Session IV:

In session 4 BGT was administered on which the client scored 0 which indicated that the client is
not neurologically impaired.

Standard progressive matrix (SPM) was administered. Client acquired a score of 50 and fell
under the 75th percentile which indicated that the client was above average.

Session V:

In session 5 TAT was administered, only those cards were administered which were relevant to
the client’s problem.

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken.

Session VI:
 27

Cognitive restructuring, a technique of CBT was used to facilitate the client in understanding
unhappy feelings and moods and for challenging the negative automatic beliefs that lie behind
them. This was done in 7 steps

1. Calm yourself
2. Identify the situation
3. Analyze your mood
4. Identify negative thoughts
5. Find objective supportive evidence
6. Identify fair and balanced thoughts
7. Monitor your present mood

After cognitive restructuring, the client realized to some extent that he wasn’t actually a
failure and that he was making efforts to earn a living and run the family and understood that
his mother at the same time was also worried about what had happened all of a sudden and
that she also lost her husband in a way, she expressed her worry and expectation in a harsh
way. Client reported that now it had started to make sense but was still stressed about getting
a job with a good package. He was called for counseling in the next session and was asked to
think about possible alternate job opportunities and discuss them in the next session.

Session VII:

In this session client reported that he was feeling a bit better. Counseling was done and
client-centered approach was used, the client then himself gave suggestions about where he
could apply for a job other than his specific field or an office job. He said he would start
applying in schools and colleges for lectureship, he could increase the amount of students for
home tuition and he also said that there was no harm in applying in a mart as a salesman for
that too is a source of income. While discussing this, he reported that he had already applied
in two schools and was waiting for their response. Client was appreciated and motivated to
go for the options he came up with regarding the job.

In this session client’s mother was psychoeducated and her counseling was done as well.
Client’s mother was also suggested to contribute financially by sewing clothes for neighbors
or relatives, as she reported that she sews pretty well. Client’s mother was first a bit hesitant
 28

but after a few minutes she said she would start sewing and contribute, she then herself said
that something would be better than nothing and that she would not burden her son by putting
it all on his shoulders.

Session VIII:

In this session Mr. A seemed happy and relaxed, he reported that he reported that he received an
interview call from one of the schools he applied in. He had an interview next week and was
positive about it. He also reported that his mother had started taking care of him again and that
she was planning to start sewing clothes and contribute financially, he said he didn’t want his
mother to work but her changed behavior made him feel better and relaxed.

The session was then terminated with the mutual consent of the both the client and the therapist.
Client was motivated that he could and had the ability to cope with future difficulties and was
also told to take follow ups if needed.

Assessments

Evaluative Techniques/ Interpretation

1. House Tree Person (HTP)

2. Beck Depression Inventory (BDI)
3. Rotter Incomplete Sentence Blank (RISB)
4. Raven Standard Progressive Matrix (RSPM)
5. Bender Gestalt Test (BGT)
6. Thematic Apperception Test (TAT)

House Tree Person (HTP)

The HTP of the client depicted restrictive and controlling home environment, need for warmth,
indecision, sense of insecurity, introversion. It also indicated aggression, assertiveness and that
the client wants to get power over his environment.

Beck Depression Inventory

 29

Client scored 33 on BDI which indicated severe depression.

Rotter Incomplete Sentence Blank

Client scored 148 on RISB which indicated that the client was socially maladjusted as the score
is above the cutoff score that is 135. The results showed that the problem was in personal and
general domain.

Raven Standard Progressive Matrix

Client acquired a score of 50 and grade II that fell under 75th percentile which indicated that the
client was intellectually above average.

Bender Gestalt Test

Client scored 0 on BGT which indicated an absence of visuoconstructive deficits or brain

impairments.

Thematic Apperception Test

The stories of the client were adequate to the client’s problem. The interpretation of client’s TAT
stories indicated need for passivity, succorance, affiliation, autonomy, and nurturance. It also
indicated unsupportive environment.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis of the client was moderately favorable as the client was cooperative and actively
participating in the sessions.
 30

Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to manage and deal with his problems efficiently. He was also told to take
follow ups in future if needed.
 31

References

Beck, A. T., Epstein, N., & Harrison, R. (1983). Cognitions, attitudes and personality dimensions
in depression. British Journal of Cognitive Psychotherapy.
 32

APPENDIX
 33

Case: 4

Total sessions: 8

Persistent Depressive Disorder

Depression is a common and serious medical illness that negatively affects how you feel, the
way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of
sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional
and physical problems and can decrease a person’s ability to function at work and at home.

Agency/Setting

The case was taken from Fauji Foundation Hospital, Rawalpindi.

Background of Client/ Demographic detail

Name: Ms. N
Age: 20
Gender: Female
Birth Order: Last born
Education: Intermediate
Marital Status: Single
Residence: Rawalpindi
Source of referral

Client was brought to the hospital by her mother.

Presenting Complaints

According to client’s mother:

“Pareshan rehti hai, weight bhi isne bohat gain krlia hai, koi kaam bhi nahi karti laikin jab kuch
kaho toh kehti hai himmat nahi hai, pehle se ziada sone lagi hai ye, apni dost ko yaad karti rehti
hai. Medical kay admission ko le kr isne apni ye halat bana li hai, kuch samjh nahi arha kia kren”
 34

According to client:

“Maine apne khawab ko paane k lie bohat mehnat ki thi, wo bhi pura nahi ho saka, usk peeche
maine apni sbse achi dost bhi kho di, kuch acha nahi laga phir, 2 saal zaya krdie hain maine”

History of Present Illness

Client’s problem started 2 years ago when she gave medical entry for the second time, but she
couldn’t clear it in her second attempt either. Client said that she had studied really hard for the
entry test, she had put aside all extra-curricular activities and paid attention just on the
preparation of the entry test. When it was her first attempt and she couldn’t clear it, she reported
that she didn’t lose hope and she was motivated by her family and her best friend for a second
attempt and that she could make it as she was an intelligent and a hard working student. She said
she studied and worked even harder for the second attempt of the entry test but still didn’t get
selected which made her extremely upset and she lost hope. Her family was supportive but she
felt like a failure and gave up after the second attempt. Her dream was to be a doctor since she
was a child, she said she tried her best and that she had always attainted first position throughout
her school and college life, she couldn’t understand where she went wrong. She reported that her
best friend had been selected the first time she gave the entry test and it had been one year, she
shared how her classes went and kept motivating the client that she would clear the second
attempt and then they would be in the same institute and be doctors together. But when she
couldn’t clear the test the second time she then after two weeks cut off with her best friend not
out of jealousy but because when her best friend used to talk about how her classes were going
and her busy routine then the client would get more upset and didn’t want to hear about her
friend’s class or routine. Client’s symptoms were progressive in nature, she had started sleeping
a lot, she had gained weight as she started overeating, isolated herself and kept sitting all day
long yet felt fatigued, she stopped making and taking decisions about anything and considered
the future as being hopeless because she lost her dream. Her family tried talking to her about
getting an admission in some other field and institution but she didn’t feel like talking about it.
Client reported that she had started to sleep more than usual because it helped her relax for a
while, she also reported that she had started to miss her best friend and she realized that she
shouldn’t have cut her off like that but she didn’t know what to do at that moment as she was
upset.
 35

Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History

No significant past medical history was reported.

Family history

Ms. N was living in a nuclear family and belonged to a middle class family. She lived in
Rawalpindi. Both her parents were alive, she had one brother and one sister. She reported to have
good relations with them. She was more close to her mother and her elder brother and shared
everything with them. There was no family history of psychological disorder.

Personal History

Ms. N was 20 years old and had done Fsc Pre Medical. Client’s birth was normal without any
complications and achieved all milestones on time. She was an intelligent, hardworking and a
good student throughout her student life. Client reported that she was good to everyone but she
didn’t make many friends, she enjoyed with her cousins and loved spending time with them.

Premorbid Personality

Ms. N was talkative, active, naughty and fun loving before the onset of her symptoms. She used
to talk to her best friend, spend time with her family, she had maintained herself and was smart,
she loved to go to parks and for outing with her family before the onset of her symptoms.

Mental Status Examination (MSE)/ Observation

A young aged 20 year old girl who was neat and clean in appearance. Client was well oriented
about time, place and setting and had insight about her problem and openly discussed the
problems. She was cooperative, attentive and had a soft tone during the session. No formal
thought disorder was found.

Diagnosis

300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)

 36

Case Conceptualization/ Theoretical Orientation

According to Beck’s cognitive model of depression, people with depression develop cognitive
distortions, a type of cognitive bias sometimes also referred to as faulty or unhelpful thinking
patterns. People with depression will tend to quickly overlook their positive attributes and
disqualify their accomplishments as being minor or meaningless. Depressed people view their
lives as devoid of pleasure or reward, presenting insuperable obstacles to achieving their
important goals. This is often manifested as a lack of motivation and leads to the depressed
person feeling further withdrawal and isolation as they may be seen as lazy by others. Expecting
their efforts to end in failure, they are reluctant to commit themselves to growth-oriented goals,
and their activity level drops. Believing that they cannot affect the outcome of various situations,
they experience a desire to avoid such situations (Beck, A. T. 1979)

Similar was the case with the client, she had overgeneralized her experience of failure and started
thinking that she would again fail the test even after working hard for it, she became demotivated
and overlooked her previous accomplishments.

Progression of Therapy (No. of sessions)

Eight sessions were conducted

Session I:

The first session was of 45 minutes. In this session presenting complaints and the causes of the
presenting complaints were taken from the client. Demographics were also taken in this session.
The client openly talked about her problem and how she had been feeling because of her
problem, she stated that she didn’t know what to do so she isolated herself. She had started
feeling like a failure and didn’t want to talk to anyone. She also reported that her family was
supportive but she felt as if she had failed them too.

Session II:

During second session personal and family history was taken from the client. BDI and HTP were
also conducted with the client in this session.
 37

Session III:

In the third session RISB and BGT were conducted with the client which indicated that the client
is not neurologically impaired.

An activity was also made for the client with the client’s consent. Activities included doing
household chores like cleaning her bedroom, making breakfast, cleaning dishes etc. And she
was also motivated to start exercising as it was good not only for her physical health but mental
health as well.

Session IV:

This session started by inquiring from the client about the activity chart and how much the client
followed it. She reported that the first day she just cleaned her room and made breakfast after
that she felt tired. The next day she tried to follow all activities on the chart and by the end of the
week she had completed all the activities mentioned on the chart. She said she enjoyed the
exercise part the most as it made her feel fresh even though she thought that it would be boring
and tiring.

TAT was also administered in this session, only those cards were administered which were
relevant to the client’s problem. Client’s stories were adequate to the client’s problem.

Session V:

In this session SPM was administered which indicated that the client was intellectually above
average. She was hesitating at first and kept saying that she won’t be able to do it and that she
won’t score good on it, she was motivated and told that she could do it and that she should give it
a try. She was also reinforced while conducting SPM.

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken.
 38

Session VI:

Techniques of CBT were used which indluded, Evaluating and Challenging Thoughts technique
was also used in which the client was asked to define failure and success. While talking about
failure client herself realized that not being able to clear one test or achieve one goal doesn’t
make a person a failure for life and she recalled that she had attained her goals other than her
goal/dream to become a doctor. Reframing Overgeneralization technique was also used to
facilitate the client identify negative unhelpful thoughts and replace them with more positive
empowering thoughts.

At the end of this session the client realized that she had many accomplishments and that her
hard work always did pay off she also realized that giving up isn’t an option and one should look
for alternate solutions.

Session VII:

In this session Cost and Benefit Analysis technique was used to facilitate the client in
understanding what are the advantages and disadvantages of not applying for further studies and
then make a decision accordingly.

Career counseling was also done and client centered approach was used. Client was asked
whether she wanted to give the entry test once more and make her dream come true upon which
the client said that she no longer wanted to be a doctor. She wanted to graduate in some other
field. She was then asked to think about the field she wanted to opt, she said she had been
intrigued by Psychology, the way this subject and profession helps people understand them and
help them with their problems. She asked if she could get an admission in Psychology, she was
told that she definitely could and that she should think about it and then take a decision. She was
appreciated and motivated to search for universities that offered Bachelors in Psychology and
apply accordingly.

In this session Interpersonal therapywas used to improve client’s relationship with her best friend
whom the client had been missing and wanted to get in touch with again. The client was asked
how she could make things better, she said that she would call her best friend and explain
everything to her but the client was hesitant to call. She expressed that what if her best friend
 39

doesn’t answer the call then role play was done and the client was motivated to call her best
friend.

Session VIII:

In this session the client seemed happy and reported that her best friend did answer her call and
she had an understanding attitude and was happy to hear about the decision client took regarding
her education. Client also reported that her best friend said that she was worried about the client
and that she tried to contact the client several times but the client’s number was powered off.
Client was motivated to remain in touch with her best friend and also take a decision to meet her
in person.

The client had done her homework and searched for universities offering BS Psychology and she
said she would apply as soon as the admissions open.

The session was then terminated with the mutual consent of the both the client and the therapist.
Client was appreciated for being cooperative and active in the therapy sessions. Client was
motivated that she could and had the ability to cope with future difficulties and was also told to
take follow ups if needed.

Assessments

Evaluative Techniques/ Interpretation

1. House Tree Person (HTP)

2. Beck Depression Inventory (BDI)
3. Rotter Incomplete Sentence Blank (RISB)
4. Raven Standard Progressive Matrices (RSPM)
5. Bender Gestalt Test (BGT)
6. Thematic Apperception Test (TAT)

House Tree Person (HTP)

The HTP of the client depicted discontent, withdrawal, immaturity, dependency, confused
thinking and lack of confidence. It also indicated discouragement, tension, and ambitions for
accomplishment, depression, insecurity and introversion.
 40

Beck Depression Inventory

Client scored 29 on BDI which indicated severe depression.

Rotter Incomplete Sentence Blank

Client scored 126 on RISB which indicates that the client was socially adjusted as the score was
below the cutoff score that is 135. The results showed that the problem was in personal domain.

Raven Standard Progressive Matrices (RSPM)

Client acquired a score of 54 and grade II that fell under 90th percentile which indicated that the
client was intellectually above average.

Bender Gestalt Test

Client scored 1 on BGT which indicated an absence of visuoconstructive deficits or brain

impairments.

Thematic Apperception Test

The stories of the client were adequate to the client’s problem. The interpretation of client’s TAT
stories indicated need for achievement, succorance, affiliation and cogzinance.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis of the client was moderately favorable as the client was cooperative and actively
participating in the sessions.

Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to manage and deal with her problems efficiently. She was also told to take
follow ups in future if needed.
 41

References

Beck, Aaron, T (1979). Cognitive Therapy of Depression. New York: The Guilford Press
 42

APPENDIX
 43

Case: 5
Number of Sessions:
Eight sessions were conducted with the client.
Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a
number of different things. People with GAD may anticipate disaster and may be overly
concerned about money, health, family, work, or other issues. Individuals with GAD find it
difficult to control their worry. They may worry more than seems warranted about actual events
or may expect the worst even when there is no apparent reason for concern.

Agency/ Setting:
The case was taken from Fauji Foundation Hospital.
Background of Client/ Demographic details
Name Ms. D

Age 24 years

Gender Female

Education BS sociology

Marital status Unmarried

Occupation Teacher

Residence Rawalpindi

Birth order Eldest

Parents’ status Alive

No. of siblings 1 sister, 2 brothers

Source of referral

Client was self-referred.

 44

Presenting complaints

“Shoulders pull hoye rhty hain. Back pain aksar rhta hy. Nend bhi thek sy nae ati aksr ankh khul
jaye tu wapis can’t sleep. Hr choti bat ki zrort sy zada tension hoti hy. Feel like job manage nae
ho paa rahi and I feel main achi bhi nae dikhti zada tar. ”

History of present illness

According to the client her problem started exactly 1 year ago, when her engagement ended. She
reported that before her engagement she and her fiancé were in contact with each other for three
months. She stated that he really cared for her and surprised her with many gifts every now and
then. Eventually she got emotionally attached to him. She told that he proposed her and later on
they got engaged by the willingness of families. Client reported that they were happy together at
the start of their relationship but after a few weeks her fiancé started complaining about her
complexion and weight. Every other day he asked her to visit saloons and get treatments. She
reported that she started to visit saloons more often then, including various visit to fitness
experts. She became conscious about her appearance and started losing her confidence. She cut
off with most of her friends and family. She further added that after four months of their
engagement he officially ended their engagement. According to client her fiancé blamed her for
end of this relation as per she was not coming up to his expectations. So this made her anxious
and her health deteriorated with the passage of time and she remained stressed, started feeling
restless and irritable. She also had difficulty concentrating at workplace and household chores.

Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History
No significant past medical history was reported.
Family history

Client was 24 years old, unmarried female belonging to an upper middle class family. She lived
in a nuclear family in Rawalpindi. Her parents were alive. She was 2 nd born. Client reported
really good relations with her parents and siblings. All of her siblings were unmarried. Client
 45

reported a close and warm relationship with her mother. There was no family history of
psychological disorder.

Personal history

Client’s birth was normal and she achieved all the milestones on time. Her school life went
smooth and she was a good student of her class. She enjoyed cooking a lot and gardening was
her hobby. At college and university level she did well in studies and also took part in co-
curricular activities. She reported that she was friendly and enjoyed hanging around with friends.
She completed her graduation in sociology and got a job as a teacher in a renowned school. She
said that she was happy to get the job. She said that she was spending a blessed life.

Premorbid personality

Client had an ambivert personality. She was quite open with her friends and family. She loved
doing her job and had very good relationship with her colleagues. Moreover she loved gardening
and planting different flowers in her lawn.

Mental State Examination/ Observation

Apparently the outlook was tidy. She was wearing neat clothes with properly combed hair. She
maintained eye contact. Client was well oriented about time, place and setting and had insight
about her problem and openly discussed the problems. Client was attentive during the sessions.
Assessment also revealed that client’s short term and long term memory was intact. Moreover
client’s perception was appropriate.
Diagnosis
300.02 (F41.1) Generalized Anxiety Disorder
Case Conceptualization/ Theoretical Orientation
Wells (1995) distinguishes between Type I worry and Type II worry present specifically in
clients with GAD. According to him, Type I worry concerns external daily events while Type II
worry is basically worried about worry. The combination of the two types of worry and
subsequent positive and negative beliefs about worrying together maintain the cycle of GAD and
worsens the symptoms. (Wells, 1995)
 46

Similarly, the client was also worried about daily life concerns compromising her Type I worry.
But on the other hand she had both positive and negative beliefs about worry creating cognitive
dissonance and thus anxiety in her. The constant back and forth movement of the client between
Type I and II worry was being distressful and symptomatic for the client.

Progression of therapy (No. of sessions)

Seven sessions were conducted.

Session I

The first session was of 40 minutes. Client was willing to improve her condition and was open
about the problems she was facing, so rapport was built easily. In this session client’s
demographic details were taken, presenting complaints and the causes that led to the presenting
complaints were explored. While talking about the precipitating event the client became sad and
quiet for a while but after a pause she completed her story.

Session II

During second session detailed family and personal history was taken. BAI and BGT were
administered in the session.

Session III

Session 3rd was started with relaxation technique as client seemed stressed. In this session RISB
and HTP was administered.

Session IV

In 4th session SPM was administered on the client.

Session V

In this session TAT was administered on the client, only those cards were applied which were
relevant to the client’s problem. PMR was also done with the client after which the client felt
relaxed.
 47

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken.

Session VI

In this session distinguishing thoughts from factsatechnique of CBT was used which was done in
two steps. The first step comprised of A-B-C technique and second step was thoughts versus
facts. Through this technique the client realized that the same event gave rise to different
thoughts that led to different feelings and behaviors and that her negative thoughts led to
negative feelings and vice versa.

Session VII

In this session Cost benefit analysis technique was used. The client was told to list down the
advantages and disadvantages of the most disturbing thought to her. She was then told to replace
the negative thought with a positive one and list down the advantages and disadvantages of that
positive thought. At the end of the session she was told to take a look at the advantages and
disadvantages of both thoughts and opt the one which had more advantages and less
disadvantages.

Session VIII:

In this session the client seemed a bit relaxed and reported that she had considered the
advantages and disadvantages once again and after that she decided to focus on the positive
thoughts and adopt healthy behaviors in order to perform actively and efficiently at work and
also spend time with her friends without being anxious.

The session was then terminated with the mutual consent of the both the client and the therapist.
Client was motivated that he could and had the ability to cope with future difficulties and was
also told to take follow ups if needed.
 48

Assessment

Evaluative Techniques/ Interpretation

 Human Tree Person (HTP)

 Raven Standard Progressive Matrices (RSPM)
 Bender Gestalt Test (BGT)
 Rotter Incomplete Sentence Blank(RISB)
 Thematic Apperception Test (TAT)
 Beck Anxiety Inventory (BAI)

Human Tree Person (HTP)

The HTP of the client indicated anxiety, insecurity, dependency and tension. It also indicated
lack of psychological warmth and need for emotional protection.

Raven Standard Progressive Matrices (RSPM)

Client acquired a score of 45 and grade II that fell under 75th percentile which indicated that the
client was intellectually above average.

Bender Gestalt Test (BGT)

Client scored 3 on BGT which indicated client was not neurologically impaired.

Rotter Incomplete Sentence Blank (RISB)

Client scored 145 on RISB which indicates that the client was socially not adjusted as the score
is above the cutoff score that is 135. The results showed that the problem was in personal
domain.

Thematic Apperception Test (TAT)

The stories of the client were adequate to the client’s problem. The interpretation of client’s TAT
stories indicated need for nurturance, affiliation, succorance and autonomy.

Beck Anxiety Inventory (BAI)

Client scored 26 on BAI which indicated that the client had severe anxiety.
 49

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis was favorable as client was educated and understood the things easily. Moreover she
was willing to change her life.

Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to manage and deal with her problems efficiently. She was also told to take
follow ups in future if needed.
 50

References

Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder.
Behavioral and Cognitive Psychotherapy, 23, 301–320.
 51

APPENDIX
 52

Case: 6

Total sessions: 8

Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a complex developmental condition that involves persistent
challenges in social interaction, speech and nonverbal communication, and restricted/repetitive
behaviors. The effects of ASD and the severity of symptoms are different in each person.

Agency/Setting

The case was taken from Benazir Bhutto Hospital.

Background of Client/ Demographic detail

Name: Ms. S
Age: 10 years
Gender: Female
Education: Grade 1
Birth Order: Only child
Father’s Occupation: Businessman
Mother’s Occupation: Housekeeper
Residence: Rawalpindi

Source of referral

Client was brought to the hospital by her parents.

Presenting Complaints

According to the client’s mother

“Ghulna milna bilkul pasand nahi, dusro se baat karne mei tangi hoti hai, apni baat theek se nahi
samjha paati, aik baat ya lafz ko bar bar dhorati hai aur ajeeb awazen nikalti hai, aksar gusa kar
jati hai, zara sa kuch change ho toh bohat disturb hojati hai”
 53

History of Present Illness

Client was a full-term baby delivered with a low birth weight of 3.5 pounds. Client’s mother

reported that client had high temperature at the age of 06 months she suffered from atrial sepal

deficit. She had delayed milestone, she started sitting at the age of the 09 months, walking at 2.5

years and uttered her first at 4 years. She started to have proper eye contact at the age of 06

years. She had problem in speech; she neither used verbal nor nonverbal skills, lacked spoken

language and also couldn’t comprehend it, didn’t understand instructions, had poor peer

relationships; she couldn’t form or sustain relations, she didn’t play around with her siblings or

age-mates, she liked to be alone and preferred solitary activities. Client’s mother also reported

that client couldn’t hold a pencil, had poor griping skills, had poor writing skills and couldn’t

follow commands, got disturbed with a slight change in routine, repeated same words (echolalia).

She couldn’t dress and undress herself, she wasn’t toilet trained and someone had to assist her.

Her attention span and concentration level was very poor. With time her symptomology

increased and became more evident, it first became evident when she went to school and had

difficulties responding to commands, making friends and learning. After which the school

principal recommended the client’s parent to get their daughter an admission in special school,

client was still having difficulties and was then referred to consult a psychologist.

Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History

No significant past medical history was reported.

 54

Family history

Client was 10 years old girl and was the only child. She belonged to a middle class family. Her
parents were alive. Her father was a businessman and mother was a house wife. Client’s relation
with her mother was good. There was no family history of psychological disorder.

Personal History

Client’s birth was normal but she had delayed milestones as reported by her mother and had a
low birth weight of 3.5 pounds. She started sitting at the age of the 09 months, walking at 2.5
years and uttered her first at 4 years. She started to have proper eye contact at the age of 6 years.
She started to go to school at the age of 6 years her academic performance was poor. She didn’t
follow instructions and picking ability was slow, she did not seem to take interest or participate
in activities. Her relationship and behavior with peers was troubling. After a few months the
school principal recommended the client’s parents to get their daughter admission in special
school.

Premorbid personality

The client had no pre-morbid personality as she was suffering from the neurological disorder,
hence affecting her gradually.

Mental State Examination/ Observation

The client was not cooperative and unwilling; she appeared to be hygienic as she was dressed up
in neat and clean clothes but her hair were not properly done. She did not sit during the whole
session. She was in a restless state. Pitch of her voice was low and she had unclear, unremarkable
and delayed speech. Her mood was flat and inappropriate. Orientation towards time, place and
person were not present.

Diagnosis

299.00 (F84.0) Autism Spectrum Disorder

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Case Conceptualization/ Theoretical Orientation

Prematurity and low birth weight factors may support the client’s situation. According to this a
number of studies have assessed risk of general psychiatric and behavioral problems in children
born with a low or very low birth weight. Rates of actual diagnosed ASD among children who
had been born at a very low birth weight. For example, a study at the U.S. Centers for Disease
Control and Prevention (CDC) compared children who had been born at a normal birth weight
with those who had been born weighing less than 2500 grams (or about 5 pounds 8 ounces).
These researchers found that the risk of autism was approximately doubled for the low birth
weight children overall. (Gardener, H., Spiegelman, D., & Buka, S. L. 2009)

Similarly the client had low birth weight which resulted in symptoms of autism spectrum
disorder.

Progression of therapy (No. of sessions)

There were seven sessions taken with client accordingly:

Session I:

In 1st session relevant history was taken from client’s referral related to her described problem
and mental status was examined. Briefly client’s mother reported that she had poor social
interaction and preferred to live alone for most part of the day. In this session Childhood Autism
Rating Scale (CARS) was also administered in order to get information regarding client’s
symptoms and condition.

Session II:

In 2nd session client seemed relatively low her mother informed that she was suffering with fever.

In this session detailed childhood, developmental, family, medical, occupational and educational

history was taken from the client’s referral.

 56

Session III:

In this session portage guide was filled by her mother and client was taken to the Occupational
therapist for some physical therapies. After the session client seemed relaxed and happy.

Session IV:

In 4th session client was taken to Occupational therapist for some physical therapies once again.
Client’s parents were psychoeducated and recommended to take the client to speech therapist for
improvement of verbal communication and interaction with others.

Session V:

In this session on the basis of evaluation done in previous sessions Applied Behavior Analysis
(ABA) was introduced. Few tasks of the ABA were administered in this session. Play therapy
was also conducted.

Session VI:

In this session client entered the room with happy mood. Pivotal Response Training (PRT) a type
of ABA was for child’s development like self-management and taking charge in social situations.

Session VII:

In 7th session parents were briefed about client’s condition and they were psychoeducated to must
continue these therapeutic techniques at home and keep visiting the occupational and speech
therapist. Client still was on progression.

Assessments

Evaluative Techniques/ Interpretation

1. Childhood Autism Rating Scale (CARS)

2. Portage Guide
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Children Autism Rating Scale: (CARS)

Childhood Autism Rating Scale was completed utilizing information provided by client’s parents
and observation and evaluation, the client received an overall rating score of 44, placing her
within severe autistic range.

Portage Guide

Portage guide abilities checklist was completed by her mother based on daily observations,
which overall showed that her participation in daily tasks was minimal and she was poor in play
and social skills, coordination, and self-expression concerns.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis was moderately favorable as client’s parents were showing cooperation. Client was
also being indulged in different programs and her response was considerable for the starting
therapy sessions.

References

Gardener, H., Spiegelman, D., & Buka, S. L. (2009). Prenatal risk factors for autism:

Comprehensive meta-analysis. The British Journal of Psychiatry: The Journal of Mental

Science, 195(1), 7-14

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 59

APPENDIX

Case: 7
Number of Sessions:
 60

Nine sessions were conducted with the client.

Major Depressive Disorder

Depression is a common and serious medical illness that negatively affects how you feel, the
way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of
sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional
and physical problems and can decrease a person’s ability to function at work and at home.

Agency/ Setting:
The case was taken from Fauji Foundation Hospital.
Background of Client/ Demographic details
Name Mr. H

Age 32 years

Gender Male

Education Masters (IR)

Marital status Widower

Occupation Police officer

Residence Rawalpindi

Birth order First born

Parents’ status Alive

Source of referral

Client was brought to the hospital by his brother.

Presenting complaints
 61

According to client’s brother

“Udaas rehne lagay hain bhai, ziada waqt soye rehte hain, baiti hai inki choti si usko bhi dant
dete hain, wo toh masoom hai magar bhai gusa kar dete hain us pe”

According to the client

“Bohat khali pan hai zindagi mei, akela sa hogya hon kuch acha nahi lag rha. Kisi kaam mei dil
nahi lag rha job pe bhi nahi ja paa raha, bus niend ai rehti hai thaka thaka mehsoos karta hon.
Bus pareshan sa rhne laga hon”

History of present illness

Client’s problem started 5 months ago after the death of his wife in a car accident. Client
reported that he had been married since the past 8 years and those eight years were the best
years of his life. He said that he had never thought that things would turn out to be this way, this
event was very distressing for the client. He further added that he was very anxious about her
daughter’s future. He informed that his daughter was just 6 years old and her grandmother was
taking care of her now, he couldn’t see her daughter upset like that as she had also been crying
and missing her mother after the accident. But he was unable to take care of her as he felt tired,
depressed and sleepy most of the time. He also reported that when her daughter came to him he
scolded her and got irritated but felt bad later. This change resulted in symptoms such as excess
of sleep, poor appetite, low energy, crying spells and loss of interest in every activity.

Past Psychiatric History

No significant past psychiatric history was reported.
Past Medical History
No significant past psychiatric history was reported.
Family history

Client was 32 years old, widower male belonging to a middle class family. He lived in a joint
family in Rawalpindi. His parents were alive and had one brother. His father was a police officer
and mother was a nurse. Client reported affectionate relations with his parents and brother. There
was no family history of psychological disorder.
 62

Personal history

Client’s birth was normal and he achieved all the milestones on time. His school life went
smooth and he was a bright student of his class. He was a good football player and won many
competitions. At college and university level he did well in studies and continued playing
football matches too. He reported to have many friends at till now. He completed his Master’s
degree in International Relations and got a job as a police officer. Client got married at the age of
25 and had a 6 year old daughter. He reported that he had good relation with them.

Premorbid personality

Client had an extrovert personality. He was very jolly and outgoing. His job was his passion and
he loved spending time with his family. Moreover he used to play football and enjoyed his life at
fullest.

Mental State Examination/ Observation

Apparently the outlook was tidy. He was wearing neat clothes with properly combed hair. He
maintained eye contact. Client was well oriented about time, place and setting and had insight
about his problem and openly discussed the problems. Client was attentive during the sessions.
Assessment also revealed that client’s short term and long term memory was intact. Moreover
client’s perception was appropriate.
Diagnosis
296.23 (F32.2) Major Depressive Disorder
Case Conceptualization/ Theoretical Orientation
According to Behaviorist Theory/Operant conditioning depression is caused by the removal of
positive reinforcement from the environment. Certain events, such as losing your job, induce
depression because they reduce positive reinforcement from others (e.g. being around people
who like you). Depressed people usually become much less socially active. In addition
depression can also be caused through inadvertent reinforcement of depressed behavior by
others. For example, when a loved one is lost; an important source of positive reinforcement has
lost as well. This leads to inactivity. The main source of reinforcement is now the sympathy and
attention of friends and relatives. (Lewinsohn, 1974).
 63

However this tends to reinforce maladaptive behavior i.e. weeping, complaining, and talking of
suicide. This eventually alienates even close friends leading to even less reinforcement,
increasing social isolation and unhappiness. In other words depression is a vicious cycle in which
the person is driven further and further down. (Lewinsohn, 1974).

Also if the person lacks social skills or has a very rigid personality structure they may find it
difficult to make the adjustments needed to look for new and alternative sources of
reinforcement. So they get locked into a negative downward spiral. (Lewinsohn, 1974).

Likewise, client lost his loved one who was an important source of positive reinforcement for
him. He lost his love as well. This leaded to inactivity, increasing social isolation and
unhappiness.

Progression of therapy (No. of sessions)

Nine sessions were conducted.

Session I

The first session was of 40 minutes. Client was willing to improve his condition and was open
about the issues he was facing, so rapport was built easily. In this session client’s demographic
details were taken, presenting complaints and the causes that led to the presenting complaints
were explored. While talking about the precipitating event the client seemed very disturbed and
was having difficulty in accepting and moving on.

Session II

During second session detailed family and personal history was taken. BDI and BGT were
administered in the session.

Session III

In this session RISB and HTP was administered.

Session IV
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In 4th session SPM was administered on the client. An activity chart was made for client with
consent and willingness of client. Activity chart included increased physical activity, restoration
of healthy habits and improved parenting techniques. He was motivated to follow the activity
chart.

Session V

Session 5th was started with taking feedback of how well client has followed the activity chart
and discussion about his previous week was included. In this session TAT was also administered.

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken.

Session VI

In this session Interpersonal therapy was used, a part of Interpersonal therapy; Grief bereavement
was used. This included empathetically listening to the client and then gradually facilitating the
client to explore new activities, new area of interests and new relationships.

Session VII

Cost Benefit Analysis technique was used in this session in order to facilitate the client in
understanding the benefits and disadvantages of staying in the position he was in.

A CBT technique ‘’Filtering’’ was selected as the focus of treatment. Filtering refers to the way
many of us can somehow ignore all of the positive and good things in our day to focus solely on
the negative. It can be far too easy to dwell on a single negative aspect, even when surrounded
by an abundance of good things.

Session VIII

In this session Interpersonal therapy was continued.

Session IX
 65

In this session client’s feedback was taken, he seemed better and had a better understanding and
acceptance of his situation. He reported that he had been working on spending good time with
his daughter. The client was reinforced and appreciated for being active and following the
therapy and was motivated that he could cope with future difficulties and conflicts.

The session was terminated with the mutual consent of the both the client and the therapist. He
was also told to take follow ups in future if needed.

Assessment

Evaluative Techniques/ Interpretation

 Human Tree Person (HTP)

 Raven Standard Progressive Matrices (RSPM)
 Bender Gestalt Test (BGT)
 Rotter Incomplete Sentence Blank(RISB)
 Thematic Apperception Test (TAT)
 Beck Depression Inventory (BDI)

Human Tree Person (HTP)

The HTP of the client depicted lack of warmth, insecurity and need for emotional protection. It
also indicated emptiness and helplessness.

Raven Standard Progressive Matrices (RSPM)

Client acquired a score of 51 and grade II that fell under 90th percentile which indicated that the
client was intellectually above average.

Bender Gestalt Test (BGT)

Client scored 0 on BGT which indicated client was not neurologically impaired.

Rotter Incomplete Sentence Blank (RISB)

 66

Client scored 139 on RISB which indicates that the client was socially not adjusted as the score
is above the cutoff score that is 135. The results showed that the problem was in personal
domain.

Thematic Apperception Test (TAT)

The stories of the client were adequate to the client’s problem. The interpretation of client’s TAT
stories indicated need for nurturance, affiliation, succorance and human support. Loss and
rejection were also indicated in the client’s stories.
Beck Depression Inventory (BDI)

Client scored 34 on BDI which indicated severe depression.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis was favorable as client was educated and understood the things easily. Moreover he
was willing to improve his condition.

Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to deal with his problem. He was also told to take follow ups in future if
needed.
 67

References

Lewinsohn, P. M. (1974). A behavioral approach to depression

 68

APPENDIX
 69

Case: 8

Total Sessions: 8

Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a
number of different things. People with GAD may anticipate disaster and may be overly
concerned about money, health, family, work, or other issues. Individuals with GAD find it
difficult to control their worry. They may worry more than seems warranted about actual events
or may expect the worst even when there is no apparent reason for concern.

Agency/Setting

The case was taken from Fauji Foundation Hospital, Rawalpindi.

Background of Client/ Demographic detail

Name: Ms. I

Age: 21

Gender: Female

Birth Order Last born

Education: BS Math

Marital Status: Single

Occupation: Student

Residence: Chakbeli Khan

Source of referral

Client was recommended to visit a psychologist by a hostel colleague.

Presenting Complaints

“Koi na koi baat zehan mei ghoomti rehti hai jis ki waja se sir mei dard rhne laga hai, bechaini,
thakawat mehsoos hoti hai, na dihan de paa rahi hon na so paa rahi hon, bilawaja ki hazar sochen
pareshan karti rehti hain”

History of Present Illness

 70

Client’s problem started 7 months ago when she left her home and started staying in a hostel for
further studies, as there was no college offering BS Math in Chakbeli Khan. She reported being
worried about a lot of stuff and not being able to focus on the task she had been sent for i.e.
successfully completing her bachelors. She reported that she was the youngest and always did
worry about some things especially her tests and exams but she reported that in the past seven
months she had started worrying about almost everything and it had started affecting her life, her
studies, her health and her routine. She said she thought about her mother, what she would be
doing, what if she’s alone, what if something bad happens to her, and thoughts about her career,
her studies whether she would be able to achieve her goals or not, what is I fail to make my
parents happy. Thoughts like these kept her disturbed and consumed most of her time and
attention due to which she scored low in her first semester. The client reported that she called her
mother twice in a week and knew that everything was okay at home but still these thoughts kept
crossing her mind and she was getting tired of them. She said she wanted to focus on her studies
and study and enjoy just like her other friends and class fellows. It was getting hard for her to
control her worry due to which she became frustrated and irritable, she reported that one of her
hostel friend noticed that she (client) wasn’t getting enough sleep and looked sluggish and
worried she then talked to the client and recommended her to visit a psychologist. Client reported
that she was visiting a psychologist for the first time and that she wanted to get rid of all these
thoughts that make her worried for no reason.

Past Psychiatric History

No significant past psychiatric history was reported.

Past Medical History

No significant past medical history was reported.

Family history

Ms. I was living in a nuclear family system and belonged to a middle class family. She lived in
Chakbeli khan but currently she was living in the hostel of Post Graduate College 6th road. Her
parents were alive. She had one elder brother and a sister, her sister was married. Client reported
that she had good healthy relation with her parents and siblings. She reported that she was more
 71

close and frank with her mother and had a warm relation with her, she shared everything with
her. There was no family history of psychological disorder.

Personal History

Ms. I was 21 years old and was doing BS Math from Post Graduate College 6th road. Client’s
birth was normal without any complications and achieved all milestones on time. She reported
being an anxious child but got her tasks done and was a good student in school. She said she was
good at making friends and had a lot of friends in her neighborhood and school but now she was
preoccupied with worrisome thoughts and felt irritable but at the same time she reported that
during her first month in hostel she made two friends and three in college but because of being
irritable she couldn’t catch up with them.

Premorbid Personality

Client had an extrovert personality. She was a worrier but it never interfered with her daily life
activities, she got her work done but now she had started having difficulties completing her
work. She was a friendly and a jolly person before the onset of her symptoms

Mental Status Examination (MSE)/ Observation

A young aged 21 year old lady who was well dressed and neat and clean in appearance. Client
was well oriented about time, place and setting and had an insight about her problem. She had an
audible volume and relevant speech. No formal thought disorder was found.

Diagnosis

300.02 (F41.1) Generalized Anxiety Disorder.

Case Conceptualization/ Theoretical Orientation

Wells (1995) distinguishes between Type I worry and Type II worry present specifically in
clients with GAD. According to him, Type I worry concerns external daily events while Type II
worry is basically worried about worry. The combination of the two types of worry and
subsequent positive and negative beliefs about worrying together maintain the cycle of GAD and
worsens the symptoms. (Wells, 1995).

Similarly, the client was also worried about daily life concerns compromising her Type I worry.
But on the other hand she had both positive and negative beliefs about worry creating cognitive
 72

dissonance and thus anxiety in her. The constant back and forth movement of the client between
Type I and II worry was being distressful and symptomatic for the client.

Progression of Therapy (No. of sessions)

Eight sessions were conducted with the client.

Session I:
In the first session presenting complaints and demographics were taken from the client. Client
was worried about how she would go back to her hostel and that what if she got late for the
car/transport. An empathetic, inquiring and respectful stance was maintained, relaxation exercise
was used to make the client relaxed it was repeated three times at the end of the session.

Session II:

During second session personal and family history was taken. BAI and HTP were also conducted
with the client in this session.

While doing HTP client kept saying, I don’t know if I’m making it properly or nice. The client
was told that this is not a drawing test, draw as you want to.

Session III:

In the third session RISB and BGT were conducted with the client which indicated that the client
is not neurologically impaired.

Session IV:

In this session TAT was administered only those cards were administered which were relevant to
the client’s problem. Client’s stories were adequate to the client’s problem.

PMR was done with the client in this session and she was also motivated to do PMR exercise
whenever she felt muscle tension or fatigued due to anxiety.

Session V:

In this session SPM was administered which indicated that the client was intellectually above
average. She found SPM to be interesting and enjoyed doing it.

In this session process of therapy and client’s agreement for participating actively in the therapy
was taken.
 73

Session VI:

In this session “Suppression experiment” was used. This experiment was used to make the client
realize the paradoxical effects of controlling worry. At first, the client was asked to close her
eyes for 3 minutes and then try NOT to think of a blue rabbit. The rationale of the technique was
kept hidden. She was then asked to open her eyes and tell if she was successful in doing the job.
The client reported that all the time she was thinking of a blue rabbit although she had never
even seen one. The purpose of the technique was then explained to the client that the worries
rebound in the same manner as the image of the blue rabbit, whenever the client tries to control
them. The more she wanted to get rid of the thoughts (suppress the thoughts), the more they
come back in her mind. The experiment was helpful in making the client understand the reason
of her repetitive thoughts.

Challenging uncontrollable beliefs technique was also used in this session. Client was asked
about the times she could switch her worrying ON or OFF. The client replied that she could not
control her worrying besides trying. She was then questioned about the times she distracted
herself or got herself busy in other mental activities. It was those times when she could switch
OFF her worrying thoughts. She said that when her hostel friends asked her to play ludo with
them or watched a good movie, her thoughts didn’t disturb her and she also said that when she
was doing SPM she was having difficulty at first but when she was told to concentrate on it, she
not only enjoyed it but felt free from those thoughts for a while. The client realized about her
own controlling behaviors after the facilitation of the therapist and was convinced that worrying
can indeed be controlled. Client was also told to focus more on the solution and less on the
thought that led to worrying.

Session VII:

In this session client reported that she was able to control her worrying thoughts to some extent.

Normalizing worry technique was then used in this session and the client was educated about the
difference between normal worry and pathological worry. She was initially told that everyone in
the world worries to some extent. All individuals have worries related to their education, home,
job, relatives etc. But then she was explained the difference by putting the phenomenon of
worrying on a continuum where at one end worrying was beneficial for the individual but on the
other it was dangerous and problematic. She was educated that worry can be helpful up to a
certain point but excessive worry leads to no positive outcomes, rather a continuously stressed
brain. The normalization helped in making the client understand to create a balance in her
worrying thoughts.

Sleep hygiene tips and relapse prevention were also given in this session.
 74

Session VIII:

In this session client reported that the therapy sessions and the therapies helped her control her
worrying thoughts and she was now able to concentrate on her studies to some extent. But she
was still anxious about whether she would be able to perform well in her exams or not, Socratic
questioning was used. After which the client found the answer to her own question. The client
was appreciated for being active and following the therapy and was motivated that she could
cope with future difficulties and conflicts.

The session was then terminated with the mutual consent of the both the client and the therapist.
She was also told to take follow ups in future if needed.

Assessments

Evaluative Techniques/ Interpretation

1. House Tree Person (HTP)

2. Beck Anxiety Inventory (BAI)
3. Rotter Incomplete Sentence Blank (RISB)
4. Standard Progressive Matrix (SPM)
5. Bender Gestalt Test (BGT)
6. Thematic Apperception Test (TAT)

House Tree Person (HTP)

The HTP of the client indicated anxiety, isolation, immaturity, dependency and aggression. It
also indicated rigidity and lack of psychological warmth, tension, inaccessibility and need for
protection.

Beck Anxiety Inventory (BAI)

Client scored 26 on BAI which indicated that the client had severe anxiety.

Rotter Incomplete Sentence Blank (RISB)

Client scored 133 on RISB which indicated that the client was socially adjusted as the score was
below the cut off score that is 135. The results showed that the problem was in personal domain.
 75

Standard Progressive Matrix (SPM)

Client acquired a score of 52 and grade II that fell under 90th percentile which indicated that the
client was above average.

Bender Gestalt Test (BGT)

Client scored 1 on BGT which indicated that the client was not neurologically impaired.

Thematic Apperception Test (TAT)

The stories of the client were adequate to the client’s problem. The interpretation of client’s TAT
stories indicated need for achievement, autonomy, passivity, nurturance, affiliation and
exposition.

Therapist/ Client Orientation Dynamics

No transference or counter transference happened during the sessions between the client and the
therapist.

Prognosis

Prognosis of the client was moderately favorable as the client was cooperative and actively
participating in the sessions.

Termination

The session was terminated with the mutual consent of the both the client and the therapist as the
client was now able to manage and deal with her problems efficiently. She was also told to take
follow ups in future if needed.
 76

References

Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder.

Behavioral and Cognitive Psychotherapy, 23, 301–320.

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APPENDIX
78