Case Report

Adult Case Studies

Student’s Name: Mahrukh Nadeem

Student’s ID: 14004146004

Supervisors’ Name: Ms Haleema Adnan

--------

Department of Psychology

University of Wah Wah Cantt, Lahore

2023
 DECLARATION

I, Ms. Mahrukh Nadeem, Roll no 14004146004, Student of Clinical

Psychology in the subject of Clinical Psychology session 2014-2016, hereby declare

that the matter printed in the Adult Case Studies is my own work and has not been

printed, published and submitted in any form in any university, research institution etc

in Pakistan or abroad.

Dated: 1st July, 2022 Signature of Deponent

Mahrukh Nadeem
 CASE REPORTS COMPLETION CERTIFICATE

It is certified that the work contained in these Case Reports has been
completed by Ms. Mahrukh Nadeem, Participant Id:14004146004, under my
supervision.

Date Supervisor
1st July, 2022

Ms. Haleema Adnan

Lecturer
Dept. of Psychology
 Table of Contents

Serial No Topics Pages

1 Summary of Case Reports i-iv

2 Case 1 1-24
Appendix A

3 Case 2 25-39
Appendix B

4 Case 3 40-60
Appendix C

5 Case 4 61-83
Appendix D

6 Case 5 84-100
Appendix E

7 References
CASE REPORT NO.1 61
1

Summary of the Case

Z.A is a 31 years old healthy looking male who was presented with the
complaints of anger issues. The total numbers of session taken with the client were 7
which comprised of assessment and management. The assessment was based on
clinical interview, behavioral observation; mental status examination and anger scale
(Rashid & Siddique). The assessment results revealed that the client had traits of
aggressiveness and his reaction to stressful situations was always aggressive. The
management plan was devised according to the client’s assessment results which
includes rapport building, psychoeducation, identification of anger triggers,
relaxation exercises and distraction techniques and Cognitive behavior therapy. The
outcome of the management was satisfactory as the client was able to practice few
techniques and learned that his anger is problematic for himself and others as well.
CASE REPORT NO.1 62
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Identifying Date

Name initials: Z.A

Age: 31
Gender: Male
Marital status: Single
No. of sessions: 7
Ward: Hamza block
Date seen: 19/05/2022
Last date seen: 4/06/2022
Source and Reason for referral
The client was referred by the clinical psychologist for the assessment of
his extreme anger outbursts and unstable emotional patterns and for devising the
management plan which is helpful for the client in understanding his problem and
controlling his anger in much better way.
Presenting Complaints
The primary presenting complaint of the client, according to the psychologist
was the client’s extreme anger issues which were reported to be impacting his life in
a negative manner. The client was reported to have beating behavior and anger
reached to the height of making him paranoid.
According to the client, he feels revengeful only towards his elder
brother and loses control when he sees him.
Initial Observation
The client was behaviorally observed and interviewed in the hall under the
supervision of attendant as he was aggravated by a fight in the morning and appeared
hostile, thus in the first session the client was not able to maintain eye contact and
talk much. The client Z.A was a young man of 31 years who was neatly dressed in a
clean shalwarkameez. The client was not able to maintain an appropriate posture, he
was shivering (might be under the influence of medication or manifesting symptoms
of anger), and sitting restlessly on chair with his eyes closed and teeth clenched.
Overall the client appeared healthy and with a muscular build. The client was
found to not follow any social conventions e.g. saying salam to the therapist,
courteous smile or handshake to the fellow members.
CASE REPORT NO.1 63
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Developmental History of the Problem
The client introduced himself in the beginning of the session after being
requested several times by the therapist. The client got admission into F.H hospital 3
months ago with the complaints of aggression and beating behavior. According to
the client he has no serious issues and he has been admitted to this hospital because
his elder brother didn’t want to give him the share in property. The client said that he
considers it normal to tackle conflicts through fighting and yelling. Exploring the
client’s childhood, it was found that he was always a shy person and didn’t use to
socialize much. The client was the youngest of four brothers and feels that he has
always been neglected by his family and was scolded a lot by his father for minute
faults. Through the clinical history it was revealed that the client didn’t socialize
much and always used to spent time alone in watching television or reading his
course text book. The client didn’t have school friends, when the reason was probed
the client told that he used to get very much in fights and had abusive language thus
no one in school liked to play with him. The client also mentioned that as he was the
youngest of all he used to always listen to his parents and brothers, the client
mentions that he do not really like his eldest brother as he is always making orders to
him and if he refuse to do something the brother starts irritating him by making
negative comments about the client and insulting him in front of family and also in
social gatherings.
The client has a family fruit shop and works there, according to the file
history the client’s problem started 7 years ago when he completed his diploma in
mechanical engineering. The client mentions that 7 years ago he wanted to leave his
family business of selling fruits and start some other business and get married to the
girl he likes, but his elder brothers didn’t gave him money and enough of the share
of property and since then he feels that his brothers are jealous of him. According to
the client, he feels caged as he doesn’t get enough money from the work he is been
doing at the shop. The client recalled an incident where his elder brother was badly
beaten by him over a general argument, the client believed that he did beat his
brother but that was okay as his brother is very rude and is always against the client.
When the client was asked that whether he have some other problem that are
causing distress in his life, he mentioned that he feels embarrassed because he
doesn’t have nice clothes to wear and that is also because of his brothers who are
jealous of his good looks and doesn’t give him enough money so that he could buy
CASE REPORT NO.1 64
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good clothes. Through the clinical interview it was revealed that the client was very
particular about his appearance and considered he is very attractive and beautiful.
Background Information
Personal history. Before the admission into F.H, the client reported that he
used to work at his fruit shop under the supervision of his eldest brother, where the
client used to deal with different kinds of people. The client reported that he was
very manipulative with the customers as he had to sell and according to him in the
business it not a big deal to deceive. The client’s hobbies include watching cricket
and he likes to spend time alone in his room. In his free time he watches movies and
listen to Indian songs.
Premorbid history.Z.A was found to be a socially withdrawn person, he was
always found to be sitting quiet and didn’t interact much. The client didn’t have
friends in his personal life. Moreover the client was found to have a negative
perception of the society, he believed that the people talk behind him. The client also
didn’t have smooth relations with his family.
Family [Link] client lived in a nuclear family system with his parents
and 2 elder brothers. When the client’s parents died, their grandmother shifted with
them to look after the house. The client had an aggressive relation with his
grandmother, according to the client his grandmother used to always interfere in his
life. The client reported that since his grandmother shifted in their house, the home
environment was spoiled and things got disturbed. According to the client, he was
also neglected and scolded without any reason by his grandmother and he believed
that things were mostly in favor of his brothers and the grandmother also had a
biased attitude towards him.
CASE REPORT NO.1 65
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Z.A’s Family

B1 B2

Male Female

Average relation
Conflicted r/s

Died

Figure 1. Genogram
CASE REPORT NO.1 66
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Educational [Link] client was educated, he had done pre-engineering
and got a diploma of 2 years in mechanical engineering from a reputable institute.
According to the client he was an average student throughout his academics, in his
college he was a lonely person and didn’t have any friends. The interview revealed
that the client had abnormal traits of aggressiveness and that’s why no one used to
like him, it was also observed that the client’s reaction to stress was also abnormal in
nature and he used to react quite aggressively. The client reported one incident in
which he was teased by the group of boys and the client in response to this indulged
in a physical fight with them and also abused them.

Occupational [Link] client didn’t look for any job related to his
mechanical diploma but started working at his family fruit shop as soon as he
finished his studies. The client didn’t like his work much and wanted to start a
business but due to conflicts with his brother he was not able to get his share of
money from the family business and thus was not able to start on his own. The client
was not satisfied with his job and reported that his brothers only give him a limited
amount of money which he believed was not enough from him.
History of psychiatry and medical [Link] to the file history, the
client’s father also had neurotic traits of aggressiveness but he was never admitted in
a psychiatric facility for the treatment.
Provisional Formulation
On the basis of current information it is stated that the client’s aggressive
behavior might be determined due to genetic tendencies as the client’s father had an
aggressive nature, this might have become a predisposing factor for client in
developing anger traits. It is also formulated that the client’s aggressiveness might
be learned as he had seen his father portraying anger in most situations and Z.A also
had direct experience of his father’s aggressive nature as he used to scold and abuse
the client.
The precipitating factors that might have contributed in aggravating the
client’s problem is the frustration Z.A has to face, when he was forced to work at his
family’s fruit shop and not continue to start his own business and marry the girl he
wanted. The client’s ‘family structure’ where all power and authority was given to
the eldest brother might have maintained the client’s problem as he was continuously
faced criticism and rejection.
CASE REPORT NO.1 67
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Assessment
Following assessment tools were used to assess the client’s problem so
that the management plan can be made accordingly.

 Behavioral Observation
 Clinical Interview
 Mental Status Examination
 Behavior Checklist
 Operationalizing the term
 Baseline chart for client’s problem
 Subjective Rating
 Trait Anger and Expression Scale (Rashid & Siddique)

Behavioral [Link] observation was made in order to

understand the client’s underlying personality characteristics or traits as a means
for predicting the client’s current behavior pattern. Behavioral observation helps us
to identify maladaptive behavior patterns and thinking styles that could be changed
or reduced through the therapy (Wasik, 1984).
It was observed that the client didn’t identify his anger as a problem
and considered it a normal expression. It was also observed that the client got
easily irritated when the therapist asked questions or demanded any details.

Clinical interview.A clinical interview was taken from the client for the
purpose of assessment and to better understand the problem of the client (Spiegler,
2013). Through the clinical interview it was found that the client’s anger has become
threatening for others as well for own self as the client indulged in too much fighting
in which he physically harmed himself and others too. Through the interview with
the client it was also revealed that the client had difficulty in concentrating and
attending to what has been said by the therapist. According to the client he gets
angry because his brother provokes him by making faces, teasing him over
something. The client reported that he feels neglected because he has always been
scolded and never loved by anyone, the client also said that his brothers are jealous
from him and that’s why they irritate him. When the reason of jealousy was
explored, it came to the surface that the client had exaggerated concept of his
beauty.
CASE REPORT NO.1 68
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Through the clinical interview it was revealed that the client gets easily
provoked and lacks ability to control his impulse. The client’s thought content was
also found to be irrational as the client had extreme negative feelings about his
brother. The client reported that his family was against his that’s why they have
dumped him here.

Mental status [Link] client was assessed through mental status

examination to figure out the psychological issues (Snyderman &Rovner, 2009). The
client had an orientation of time, space and place. His both long-term and short term
memory was accurate. There were no hallucinations and delusion found in the client.
His judgment and contact with the reality was appropriate but it appeared that the
client lacked proper insight about his problem. The client’s mood and affect was
found to incongruent as when the client was asked about ‘how he is feeling?’ he
reported that he is feeling ‘good’ whereas from his facial expressions it was obvious
that the client is in distress.
The client’s mood was observed to be irritated and anxious and he reported to
feel ‘sad’ as he wanted to go home. The affect was restricted to the irritability
range and sometimes moving towards being silent. The client’s affect was noted to
be
liable, moving from irritability to anger and to sadness which depicts that the
client’s mood was congruent to his affect. Z.A was observed to be oriented to time,
place and person. However the client’s insight and judgment was found to be poor
as he was not able to accept his problem and consider his issues of anger as
problematic for him and people around him
Behavior check list. Behavior checklist is used to record the client’s
behaviors related to hygiene, social skills and vocational skills.
Personal hygiene [Link] was administered to check hygiene of the client and
it was consisted of 3 days at placement.
Table 2
Frequency of Each Behavior in Hygiene Checklist

Behaviors Day 1 Day 2 Day 3 Average

Hands    100%
Face    100%
Teeth    100%
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Feet    100%
Hair    100%
Body    100%
Clothes    100%

Qualitative [Link] recording of the behavior checklist revealed

that the client was able to maintain his hygiene conditions independently. He was a
neatly dressed young man who was very conscious about his looks and his clothing
was found to be very immaculate. It was also observed that client trimmed and
cleaned his nails regularly, wash his hands before and after taking meals and take
bath regularly.
Social skills [Link] was administered to check social skills of the client
and was maintained for 3 days in the week.
Table 3
Shows Frequency of Each Behavior in Social Skills Checklist
Behaviors Day 1 Day 2 Day 3 Frequency
Greet trainee  20%

Maintaining eye contact  20 %

Participation in group    100 %

Friendly attitude with  20%

other members

Qualitative [Link] client had anger issues and was frequently

observed to show aggressiveness during his encounter with the attendants and other
members. The client’s this problem had affected his social skills. The client lacked
basic social skills like greeting others, giving a courteous smile while meeting others
and having a friendly behavior towards other members. However he was observed to
participate in the group daily.
CASE REPORT NO.1 70
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Operationalizing the [Link] was used to know how the client defines
anger and manifests it in her own verbatim (Baumeister&Vohs, 2007).
Table 2
Operational Term and Definition of Anger according to the Client
Term Operational definition

Anger ‫جب غصہ آتا ہے تو میں دوسروں کو مارتا ہوں۔‬

‫چیختاچالتا ہوں۔‬
‫کبھی گالی بھی نکل جاتی ہے منہ سے۔‬

Qualitative [Link] client was admitted in F.H for his anger

problems, when the client was inquired about his anger problem, he reported that he
gets angry when others provoke him. The client was asked to define what he meant
by anger and how he manifests it to which the client replied that he gets angry and
starts beating others when they are constantly nagging and teasing him. The client
reported that he used to yell at his brothers when they didn’t listen to him. The client
also reported that he used abusive language sometimes and it helps us in easing his
emotions.
Baseline chart for client’s [Link] baseline chart (Spiegler, 2013) was
maintained by the therapist for recording the intensity, frequency and duration of
client anger problem for three days.
Table 3
Behavior, Frequency, Intensity and Duration of the Client
Antecedent event Feeling/Behavior Duration
 When my Shout, abuse, hit by 2-3 hours
brother teases me shouting at them

 When someone else Throwing something on Whole day

is getting angry them.
Damaging things- Threw
 When I can’t do tea cup on brother once, 4-5 hours
things according to throws anything which is in
my will hands, and punch furniture.
CASE REPORT NO.1 71
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Qualitative [Link] client was asked to rate his anger in terms of

frequency, intensity and duration of his manifestation in which the results revealed
that her anger was situational but his demonstration of anger that was extreme and it
is also observed that the client has adopted wrong ways to channelize or display his
anger which had caused a lot of damage to himself and his relations.
Subjective rating of client’s anger The client was asked to subjectively rate
his anger (how much angry he gets) from 1 to 10, where 1 depicting ‘getting angry
very much’ and 1 ‘not getting angry’.
Table 2

Subjective Rating of Presenting Complaints by the Client

Problem Pre-assessment
Shouting 9
Hitting 8
Throwing things 8
Abusing 7

Trait anger and expression scale (Rashid & Siddique). It was used to
measure anger in, anger out, anger control, state anger and trait anger as the client
had reported that he gets angry a lot and there were times in which he displayed
his anger on self and others. (Appendix D1)
Table 4
Score, Mean, SD, Range and Category of the Client on Anger scale.
Score Mean SD Range Category

61 38.30 13.75 24 - 52 Abnormal

Qualitative Interpretation. The client scored 61 which indicated anger

patterns. The client’s scores indicated that he has trait anger which is a tendency to
react to situations in anger and there were also events when he expressed state anger
which is temporary anger according to the situation and after some hours he is able
to control it. The client according to the scale expresses his anger outwardly hurt
people physically, abuse them and shout at them. The scale results further show that
CASE REPORT NO.1 72
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his inward expression of the anger is lowest. Overall it is concluded that over years
the client has developed trait anger, and has a temperament of getting angry on
small things.
Case Formulation

This is a case of young male, age 31 years who was presented with the
complaints of extreme anger problem and aggressive behavior, the case was
formulated in the light of biopsychosocial model. The history of the client reveals
that the client’s father also had anger problems and the client also reported that his
father used to scold and abuse him a lot when he was little and was not able to meet
the commands of father. Thus it is formulated that the client might have a genetic
vulnerability to react in difficult situation with aggression. According to the
biological perspective,if an individual grows with aggressive parents then they are
most likely to grow up becoming an aggressive adult (Burger, 2011). From his
childhood the client has seen his father getting angry on him, it is also suggested that
the client’s anger is learned,as according to the social learning approach the
aggressive behavior is learned through direct experience or through observation
(Burger, 2011). In the case of Z.A the chances are that the client had learned the
aggressive behavior from his father. As a child, the client grew up watching his
father yelling at him and his brothers and scolding the family members on and off,
and in this way Z.A had learned aggression through modeling and considered it an
acceptable behavior.
The client’s anger problem was precipitated when he was not allowed to
pursue with his goals and was forced to work at the family fruit shop. The client
reported that he never liked working at the fruit shop and wanted to start his own
business but his brothers never gave him the share in the property and the money he
used to get by working in the shop was also very limited. This all made the client
frustrated and he started getting irritated on every little thing, this frustration has
psychologically influence the client’s aggressive behavior. According to the
frustration aggression theory (1939), frustration creates a motive for aggression, as
the client was disapproved of starting a new business, this may had cause the client’s
aggressive behavior to be displaced against someone else or any other easily
accessed target.
CASE REPORT NO.1 73
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The client’s family structure was also observed to be maintaining the client’s
aggression. In the client’s family the property and power was not distributed with
justice, all the power was in the hands of the eldest brother, the client reports that he
used to beg for money from his eldest brother which he didn’t like. The client also
reports that his brother used to always criticize him and reject his ideas if he ever
came up with any new idea to expand the business or deal with the clients
differently. Research indicates that interpersonal rejection affects not only
aggressive behavior but also mediator of aggression such as anger and derogation of
other people (Leary, 2006).
Through the clinical interview it was revealed that the client’s response to
any stressful situation was aggressive and he didn’t accept his behavior as
problematic this might be due to the lack of moral awareness. The lack of moral
awareness of moral standards may come from the fact that the client had developed
highly biased way of interpreting the world and that is why the client is observed to
interpret the behavior of his brothers as hostile, negative and challenging and this
have given rise to client’s aggressive reactions. According to the social information
processing model (Davey, 2008), the history of trauma, abuse, deprivation and
insecure attachment may give rise to specific information processing which includes
hyper vigilance for hostile cues and attributing minor provocations to hostile intent
and as a result these biases give to unwarranted aggressive reactions.
We might include that in aggravating the client’s problem, biological as well
as socio-cognitive factors play a role. The client has developed the cognitive errors
which could be changed and the client’s reaction to stress and other situation could
be changed following a management model that focuses on behavior as well as
client’s cognition.
CASE REPORT NO.1 74
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Summary of case formulation
Assesment
Presenting Behavioral
Observation
complaints
MSE

Anger issues Clinical Interview

Shouting, hitting
Anger scale

Case formulation

Predisposing Precipitating Maintain factors

factors Factor
Genetic Lack of care by
vulnerability Forced to work at family
fruit shop
Shy and Family structure
isolated
nature

Management

Rapport building

Psychoeducation

Anger management

Relaxation exercise

Figure 2. Pictorial representation of summary of case formulation

CASE REPORT NO.1 75
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Intervention Plan
In order to deal with the client’s problem, different techniques will be used.
Following will be the goals
 Rapport will be built and maintained with the client to gain trust and confidence of
the client.
 Client has poor insight about her problem so he will be psychoeducated regarding
her problem.
 Anger management techniques will be introduced to the client to overcome his
anger issues
 Relaxation exercises will also be taught to the client to manage his irritable mood.
 On the basis of her presenting complaints and history Cognitive behavior therapy
will suggested for his negative thought patterns.

Intervention Strategies
Rapport [Link] client was found to be quite low and restricted in
sharing things initially and was stuck to the point to help him get out of the hospital.
For the reason of having the same wavelength with the client a goal of rapport
building was considered (Altman, 1990). For rapport building the client was asked
about his interest and share about his hobbies and he mentioned he likes reading
sports section of newspaper, watching cricket and movies.
Newspaper reading [Link] rapport building, news related to cricket was
brought for the client and was given to the client so that he can read and discuss his
thoughts about the cricket match. The client showed interest into this activity and
shared his views and also asked the therapist to tell her name again, which was the
goal of this activity to make the client talk with therapist.
[Link] was used for the purpose of building
insight in the client about his problem, as it was observed that the client didn’t see
his anger issues as a problem and consider them the correct way to deal situations
thus he was explained the vicious cycle of anger.
Vicious cycle of [Link] order to make the client realize how his anger is
becoming a problem for himself as well for others, he was explained the cycle of
anger. The client showed resistance towards the therapist initially but then he started
to focus on what the therapist is telling. The client was guided to the information
through the following diagram.
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INNER
WORLD
My brother hates me!

ANGRY BEHAVIOR MOOD

Irritable/
Attack/Argue/Abuse
Angry/ Enraged

BODILY SYMPTOMS
Heart racing, tense,
breathless

Figure 3. Vicious Cycle of Anger

The client was explained that all these parts of anger can affect each other
and that anger can spiral out of control. The client was also explained that angry
behavior can angry response and how bodily signs of anger can lead him to feel out of
control and this can made his mood even worse. (Appendix D2)
Identifying the anger triggers. The client was psychoeducated about the
importance of identifying the triggers and how the identification of anger triggers will
help him from losing control. The client was taught the he can change his feelings and
reaction towards thing that disturb him. The client was given a worksheet and was
asked to write down his triggers.
This activity helped the client to identify things, people, words that make him
angry and then the client was explained about the automatic thoughts that are linked to
these thing, people and other’s behaviors.
Cognitive behavioral therapy (CBT).During the history taking client’s faulty
thinking which was causing negative behaviors as well as negative emotions were highlighted,
so for this purpose A-B-C technique was done with the client so that he is able to identify his
negative thoughts about his family which are causing his aggressive behavior
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ABC Model. ABC model was used as followed so that the client may know and
understand the process.

ACTIVATING BELIEF CONSEQUENCE CONSEQUENCES

EVENT (THOUGHT) (FEELINGS) (BEHAVIORS)

• My
• He hates • I don't • Fight
brother
me like my with him
didn't let
me start • He is brother • Abuse
my own jealous of now. him
buisness. me • Get
• He didn't irritated
gave ne by him
share in easily.
the
property

Figure 2: ABCD model of negative thinking of the client in anger.

Once this was done the client was able to understand the process in which
he shows and manifests anger which is not healthy. (Appendix D2)
CASE REPORT NO.1 78
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Thoughts versus Possible facts technique. The purpose of this technique was
to provide positive possible facts about the client’s thoughts. In this the client was asked to
list down the alternatives due to which his brother could not come to meet her.

Negative Other Possible Facts

 He is not jealous, he might

need your help in the
Thoughts business

 He is jealous of me  He is not greedy, may be

that is why he forced you spent so much and
me to work at fruit carelessly that he gives you
shop. limited amount of money

 He is very  He is paying for your

greedy & has taken treatment and weekly comes
control over all to visit you, he doesn’t hate
you. He likes you but he
doesn’t like your anger.

Figure 3: Alternative of negative thoughts of the client in anger.

Distraction techniques. The client was helped with learning techniques to

distract himself from the stimulus that provokes him. Distraction techniques are
useful in helping the client to identify his triggers and then distracting himself from
these triggers effectively. Distraction is an effective anger management technique as
it helps the client to keep his mind off the things, situation, behaviors which are
making him angry.
Time out.‘Time out’ technique was taught to the client verbally in which the
client was explained to take a break from the situation which is offending you. The
client was taught that this technique can help him in feeling better and can prepare
himto handle the situations in a prepared manner without getting irritated or angry.
This client was guided to take a break when he could assess the troubling
situation and take a break in such situations. This would involve leaving the place
for five to ten minutes and then coming back and trying to resolve the issues
(Miltenberger, 1997).
CASE REPORT NO.1 79
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The client liked this technique and promised to do it when someone will be
offending him. The client said that he would go take a walk when someone will be
irritating him.
Counting to [Link] client was introduced to another technique and was
asked that if he is unable to leave the situation then he can also get hold of this
technique. The client was asked to count 10 backward and rationale was explained to
increase the reaction time.
Biting the [Link] the assessment it was revealed that the client in
the habit of abusing verbally, so in order to make the client reduce his habit he was
asked to bite his tongue every time he feels an urge to abuse. The client was asked to
keep silent when he face any situation which might trigger his anger, he can also bite
his tongue as it will help him to not open mouth and spill anger and it will also act as
a reminder that he doesn’t have to react.
Relaxation [Link] client was taught relaxation so that he can better
control his anger and better calm himself when he encounters any negative situation.
The client was explained the rational of relaxation and was taught that relaxation
will help him to think clearly and express his frustration in an assertive but
nonconfrontational way. He was also explained the benefit of this exercise that the
client will be able to state his concerns and needs clearly and directly, without
hurting others.
Deep [Link] client was asked to position himself in a relaxing
position and take a deep breath and fill his lungs and stomach with air, inhaling
through the nose. The client was asked to hold the air inside for 5 seconds and then
exhale slowly through the mouth. The client was asked to practice this daily, initially
he was made to do this exercise at the start of every session for practice.
Indulging in physical exercise. The client was also asked to indulge in a
physical activity, which is also another way to relax and help reduce stress. The
client was asked that if he feels his anger escalating he should go for a brisk walk
or spend some time doing other enjoyable physical activity.
Coping [Link] client was introduced with the coping statements,
coping statements are way to replace the negative thoughts that takeover when you
are angry. The client was given copying cards that read coping statement and the
client was asked to read this coping statement aloud. Coping statements are designed
CASE REPORT NO.1 80
1
to replace beliefs that increase your anger with those that help you lessen
anger (Raymond, 2009). (Appendix D3)

Outcome
The client was quite cooperative after the rapport was build and the client
was given insight about his problem through psychoeducation. The client attended
every session on time and played a major role in making the intervention plan
successful. He actively participated in the role plays and had dealt with his
aggression by practicing the techniques that were taught to him. Also the client got
benefit through the relaxation technique he was taught. The client’s negative
thinking was also reduced through the cognate behavior therapy and also he was able
to convert his negative statement into more positive ones after the cognitive
restructuring.
Table 5
Post- Subjective Rating of Presenting Complaints by the Client
Problem Post-assessment
Shouting 6
Hitting 6
Throwing things 5
Abusing 4
CASE REPORT NO.1 81
1

10
9

5 Pre

4 Post

3
2

0
Shouting Hitting Throwing things Abusing

Figure 5. Histogram

Limitations
Following were the limitations faced by the therapist while dealing with the
client

 Client’s record is not properly maintained and updated by clinical

psychologist. Client’s history of illness is incomplete. So therapist has to rely on
that information.
Suggestions
Following are suggestion for institution.
 Proper history of client should be maintained and updated.
 Vocational skills should be taught to the client as there is no such activity for
them to get them busy.

Student’s’s Name Supervisor’s Name

Mahrukh Nadeem Ms. Maheen Saleem
Date: 1st July, 2015
CASE REPORT NO. 5 84

Session Reports

Sessions 1

In the first session the client was behaviorally observation and interviewed
during session. A brief introduction was given to the client in which all the rules
were set to gain the confidence of client.
Sessions 2

In the second session, mental status examination and client was interviewed
for further exploration of this history of clients problem. After general talk the client
was asked the questions related to mental status examination.
Sessions 3
In this session the client was introduce to the relaxation exercises. Subjective
rating from the client was taken about his anger problems.
Sessions 4
In this session, he was asked to tell about question related to his hygiene,
social and vocational skills. The client was found to have appropriate hygiene. In
this particular session. The client was asked to tell the routine of his previous day
and later the routine of present day. However, his social skill was not appropriate.
He was found to have aggression problem.
Sessions 5

In the fifth session, distraction techniques were introduced to the client to

help him overcome his anger problem.
Sessions 6

Cognitive behavior therapy was used to elicit client’s negative thought

patterns and his negative thoughts were replaced by positive ones. In this session,
revision of the management was done with the client in sessions. The client was
helped to revise all the therapies and was told that how much he has improved. He
was once again given the chance of practicing techniques he has learned during
sessions. The client was able to revise the techniques he learned and cooperated very
well. Many techniques he could remember on his own and few were practiced again.
CASE REPORT NO. 5 85

Sessions 7

In this session the client, post subjective rating was taken for the
goals and practice of all the techniques once again to make the client responsible.
The client was asked to give subjective rating for the improvement of his problems.
Also some of the techniques were again revised to make the client independent. The
client was able to understand to give subjective rating and gave a quiet positive
feedback. He had a great insight about his problems.
 86

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