1

Case Summary

Client name AS. She was 20 years old girl. Client contacted to Psychologist due
to the presenting psychological complaints of low mood, low self-worth, lack of
confidence, lack of concentration, loss of interest and negative thoughts. 6 sessions
were conducted. According to DSM 5-TR client diagnosed with Major depressive
disorder with Recurrent Episodes 296.33 (F33.2)

Client was assessed using informal as well as formal assessment including

history taking, behavioral observation and mental state examination of presenting
complaints while for formal assessment Beck Depression Inventory (BDI) were
administered. The management plan compromised on psychoeducation, deep
breathing, meditation, relaxing techniques, good nutrition and exercise was applied as
management plan. The session process helped much in treated client problem.
 2

Introduction of Disorder

Clinical depression, also known as major depressive disorder (MDD) is a mental

health condition that causes a persistently low or depressed mood and a loss of interest
in activities that once brought joy. Clinical depression can also affect how you sleep,
your appetite and your ability to think clearly. These symptoms must be present for at
least two weeks for a diagnosis. Major depressive disorder is a serious and
incapacitating condition that can have a devastating effect on the quality of one’s life
(Lasalvia et al., 2013).

Approximately 50%–60% of people who experience an episode of major

depressive disorder will have a second episode at some point in the future; those who
have had two episodes have a 70% chance of having a third episode, and those who
have had three episodes have a 90% chance of having a fourth episode (Rothschild,
1999).

Although the episodes can last for months, a majority of people diagnosed with
this condition (around 70%) recover within a year. However, a substantial number do
not recover; around 12% show serious signs of impairment associated with major
depressive disorder after 5 years (Boland & Keller, 2009). In the long-term, many who
do recover will still show minor symptoms that fluctuate in their severity (Judd, 2012).
 3

Identifying Data

Name: AS

Age: 20

Gender: Female

Siblings: 04

Birth Order: 03

Education: FA

Marital Status: Unmarried

Informant: Herself

Religious. Islam

Session 07

Source and Reason of Referral

The client was referred by the psychiatrist to trainee clinical psychologist for
the purpose of psychological assessment and management.
 4

Presenting Complaints

Table 1.1

Presenting Complaints and Duration of Client Problems Reported by her

‫ین‬
‫دورا ہ‬ ‫ت‬
‫العام ہ‬

‫اکیاسل‬ ‫ہ‬
‫تہبزایدہاداسریتہ ہ‬

‫ھچامہ‬ ‫ہ‬
‫اکھتوٹوسحمسوہیت ہ‬

‫ھچامہ‬ ‫انادیمیتہبریتہہ‬

‫اکیاسل‬ ‫یسکزیچرپدایھنںیہندےاپیت‬k‫ہ‬

‫ھچام ہ‬ ‫وخدوکاصقنناچنہپےناکدلرکاتہ‬

‫ھچام ہ‬ ‫ہ‬
‫یسکاکمںیمدیپسچلںیہن ہ‬

‫ھچامہ‬ ‫ہ‬
‫اھکےنےنیپیکرونیٹرخاب ہ‬

Initial Observation

The client was 20 years old girl appeared clean and tidy in a casual dress and
hijab on head. Her body posture was not normal and her shoulders were bent. Client
maintained eye contact but felt hesitant to maintain it upon few questions. Client was
cooperative but client felt difficult to speak her thoughts. Client mood was low and
there was a sad expression on her face continuously. Client had a sad face and nervous
feeling as depicted though continuous pressing of fingers. client cooperated during first
visit with little reluctance in disclosing information.

History of Present Illness

The client her self-contacted due to low mood, suicidal ideation, sleeplessness,
lack of concentration, weight lost due to lack of appetite and anhedonia. According to
the client, at her childhood when she was discriminated by her parents and her brother
 5

was prioritized over her. Client reported that she never enjoyed a complete feeling client
started school at the age of 5. She was not good in studies so client never liked school.
Client reported a conflicted relationship with teachers due to her never completing the
home work. Client had difficult time completing her studies. During college life she
had a friend. Client realized that client is physically attracted to girls instead of boys
with whom client had trust issues and feeling of hatred for them. After Bachelor (B.A),
client quitted studies because of her disinterest an being confused about what to study
because client had no interest as well as guidelines.

Client started a job at a private school. Her relationship with colleagues was
constrained and client did not like talking to anyone. Client reported that client was not
happy with her job and client might quit it because of societal demands of expression
and friendliness. Client reported that client faced extreme disturbance in maintain her
prayers’ routine Client said that client tried but client could not firm her connection with
God.

Client never visited psychiatrist due to fear of society and being made fun of.
Client contacted for help due to her mood getting so low every day. Client reported that
client never get anyone at school or at family who could help her find solution for her
issues. Client reported that client was ridiculed by family for her psychological issues.
Client wanted to stay alone because client didn’t like dressing and makeup for events
so client preferred staying at home.

Background Information

Personal History

The client was 3rd among siblings in birth order and was 1 year older than her
brother. Due to immediate birth of brother. Client reported that client was never loved.
Client born through normal delivery and her weight at time of birth was 2kg. Client was
under weight and was kept in nursery to a week under supervision. Her first cry was
time appropriate. Her physical health throughout the childhood suffered due to
recurrent diseases due to weak immunity client reported no drug abuse.
 6

Education History

The schooling of client started at the age of 5 in a government school. Client

was an average student and had extreme difficulties in mathematics throughout her
education client didn’t make any friends except one friend in college with whom her
bond broken later due to her extreme attachment to her that led to fights over minor
things and so much expectations of the client from one client likes e.g. talking to nobody
else or it hurt her. After bachelor education, the client couldn’t continue her education
because client never decide what client wants to do next. Client although wants to
resume her studies but did not have any motivation as well as her indecisiveness is a
hurdle in the way to decide anything.

Sexual History

Client reached puberty at the age of 12. Her source of sexual information was
internet. Client reports extreme hatred toward men and client reported her disinterest
in getting married to any man because of her hate for them as well as her sexual
inclination towards females. client had extreme trust issues for males and finds no
interest in them.

Family History

The client belonged to a middle class, Muslim family. Client father was 55 years
old and works in a private office while her mother was 50 client was a house wife. Her
relationship with each parent was average. There was a big communication gap between
client and parents. Her relationship was particularly conflicted with her mother who
always asked her to stay silent when client tried to speak for her issues because she said
that these issues are unreal and does not exist. Her father shows little or no interest in
her matters or other siblings. He only pays attention to his son and talks only to him.
The family was nuclear but there was interference of paternal family in personal life
matters. Client was compared with other cousins and girls of her age at every gathering,
because client does not anymore like to attend any of them and prefers isolation.

Father was authoritative figure of the house. He was so inaccessible to

communicate that client reported starting a job to not ask him for money for her
 7

financial needs. Clients father relationship with her mother was also not good and he
often insults her for minor reasons.

Past Medical & Psychiatric Illness

The client reported medical issue of extreme itching in skin during past one year
for which client was taking medicines. Her stomach often disturbed and client had
stomach burning and nausea issues. There were no psychiatric issues diagnosed before.

Pre-Morbid Personality

Upon asking her pre-morbid personality, client said that when she looks back
into the past it seems like she was always the same, a girl who preferred isolation, who
feared to take part in social activities someone who never liked getting ready to go to
events because that requires dressing up and makeup because nobody accepts you with
your real face so she prefers staying at the home. Even as a child, client reported lack
of happiness and enjoyment in childhood. Client said that she never liked her family or
household and she do not like to ask+ from them for anything that’s why she started
earning for my own self. Client never made friends and she reported her extreme
sensitive nature because client get hurt by people’s minor actions since her childhood,
it although got intense during teenage.

Psychological Assessment

Psychological assessment was done at both formal and informal levels.

Informal Assessment

• History Taking
• Behavioral Observations
• Mental State examination

Formal Assessment

• Beck Depression Inventory Scale (BDI)

 8

Informal Assessment

History Taking. History taking involves a structured approach to gather

important information while ensuring the individuals comfortable. It starts with
building rapport with the client and informant, then collecting developmental history,
medical history, and behavioral observations regarding attention span and impulsivity.
Family and social histories are also important to understand any potential influences on
the client behavior (Bickley & Szilagyi, 2017).

Behavioral Observation. Behavioral observation is a method used in

psychology to assess an individual’s behavior by watching and recording their actions
in real-time. This approach focuses on specific behaviors, such as body language and
verbal communication, to gain insights into a person’s emotional state and social
interactions (Kazdin, 2017).

The client was 20 years old with 5.3 feet height and 38 KG weight that was
extremely low according to Body Mass Index. Client had a sad face and nervous feeling
as depicted though continuous pressing of fingers. Client was neatly dressed and client
cooperated during interview with little reluctance in disclosing information.

Mental State Examination. Mental State examination (MSE) is a structured

assessment used in psychology to evaluate a client cognitive, emotional, and
psychological functioning. It includes several key components, such as the client’s
appearance, behavior, speech patterns, mood, attitude and many other aspects (Bickley
& Szilagyi, 2017).

Appearance. The client was 20 years old girl enter with sad face and nervous
feelings client appeared neat and tidy in a casual dress.

Attitude. Client Attitude was very cooperative also maintained eye contact but
felt hesitant to maintain it. Client was cooperative but felt difficulties to speak her
thoughts.

Behavior. Client body posture was not normal and her shoulder were bent Her
mood was low and there was a sad expression on her face continuously.
 9

Speech. Client volume of speech was low but she speak properly with feeling
of sadness.

Mood. Client mood was depressed and express feeling of sadness hopelessness

Thought Process. Client had thought of helplessness and worthlessness Client

involve in self-critical and negative thoughts

Thought Content. Client had a persistent guilt, self-blame and negativity

Orientation

Orientation Of Person

‫یہ‬
‫آپےکرھگےکےنتکارفاد ہ‬

‫ھچ‬

Insight. Client is well aware of her problem/issue of past and present situation

‫ہ‬
‫آپوکاسیکوسحمسوہات ہ‬

‫ںیماینپزدنیگںیمتہبزدیہاداسوسحمسرکیتوہاورریمےوخدوکاصقنناچنہپےناکدلرکاتہ‬

Memory

Past Memory

‫ئ‬
‫آپاہکںدیپاوہ ہ‬

‫ےھجمںیہنہتپ‬

Recent Past Memory

‫آپےنلکایکاھک ہای‬
 10

‫آولوگتش‬

Intelligence‫ہ‬

‫ت‬
‫اچرعمجدوےنتکوہ ہ‬

‫ت‬
‫ھچوہ ہ‬

General Information

‫ہ‬
‫آپوکایکرکاندنسپ ہ‬k2‫ہ‬

‫آجلکھچکرکےنوکدلںیہنرکات‬

Perception. No hallucinations and delusions during the interview

Formal Assessment

For the formal assessment of the client following test were used

Beck Depression Inventory (Beck et al., 1979). The Beck Depression

Inventory is a 21 items scale that assesses the level of depression including cognitive,
affective, somatic, behavioral and motivational aspects as well as suicidal intentions.
Because the presenting complaints of the client matched the corresponding items of the
scales, it was use.

Table 1.2

Table Showing Score obtained in back depression inventory.

Range Client Score Level
1-10 Normal Depression
11-16 Mild mood Disturbance
17-20 Borderline Clinical Depression
21-30 Moderate Depression
31-40 36 Severe Depression
40-63 Extreme Depression
 11

Interpretation The 36 score on Beck Depression inventory (BDI) test shows

that client had severe level of Major Depressive disorder (MDD). Client problem was
on severe level. The total score of Client on BDI scale which manifest severe
depression, it suggests that the individual experiences significant issue that interfere
with her daily life. At this level, major depression was noticeable and impactful enough
to cause sever disturbance and disruption in the client functioning. It indicates a
significant level of MDD symptoms that require attention and intervention to improve
the quality of life.

Diagnosis

According to DSM 5-TR client diagnosed with Major Depressive Disorder with
Recurrent Episodes 296.33 (F33.2)

Client Prognosis

The prognosis of client was good because client had good insight of regarding
her problem and client was cooperative to resolve or treatment them.

Intervention Plans

Short Term Goal

• Rapport building was done to develop a trust worthy relationship.

• Psycho Education was done
• Making plan for managing her negative thoughts like feeling of hopelessness,
worthlessness and guilt.

Long Term Goals

• Continuation of short-term goals

• Follow up session would be conducted
• Making and apply technique for further treatment of client present illness.
 12

Treatment and Management Plans

Techniques Applied

• Rapport Building
• Psycho Education
• Mindfulness and Relaxation
• Behavioral Activation
• Deep Breathing
Rapport Building. Rapport building is a technique in therapy that focuses on
creating a trusting and empathetic relationship between the therapist and client. It
involves active listening, genuine interest, and a safe environment, which enhances
communication and therapeutic effectiveness (Rogers, 1961).

Psycho Education. Psychoeducation is a therapeutic approach that educates

individuals about their mental health conditions, enhancing understanding and coping
skills. It helps improve treatment adherence and reduces stigma (Mueser & Gingerich,
2006).

Mindfulness and Relaxation Techniques. Teach the client mindful exercise or

relaxation technique to help manage stress and stay present in the moment. Mindfulness
and relaxation techniques applied in daily life to improve well-being and reduce stress.
Incorporating relaxation techniques like progressive muscle relaxation also help simply
tense and then relax different muscle groups to release tension (Zinn, 1990).

Behavioral Activation. Behavioral activation that helps client with depression

by encouraging them to engage in meaningful activities. It focuses on increasing
positive behaviors to improve mood and reduce feelings of hopelessness (Jacobson et
al., 2001) Encourage the Client to engage in activities that client use to enjoy or find
fulfill even if client don’t feel like it. Gradually increasing positive activities can help
improved mood

Deep Breathing. Deep breathing is a relaxation technique that involves taking

slow, deep breaths to reduce stress and depressive symptoms. It helps activate the body's
relaxation response, promoting calmness and improving overall well-being (Brown &
Gerbarg, 2005).
 13

Techniques Suggested

• Relaxation Technique.

Relaxation Technique. Relaxation techniques are used to reduce stress and

promote calmness, including deep breathing, meditation, and progressive muscle
relaxation. These practices help lower stress and depressive levels and improve overall
well-being (Zinn, 1990).

Limitations

• Emotional disturbances disrupt sessions.

• Building trust be hard due to feelings of shame, and external stress complicate
therapy

Recommendations

• Properly following the treatment plan for a significant period of time

• Avoiding the precipitating factors as much as possible
• Seeking positivity provoking sources e.g. reading good nutrition and self-care.
 14

Session Report

1st Session (60 To 90) minutes

Therapists focus on building trust, learning about client struggles, History

taking was conducted, to obtain the detail history regarding the problem of the Client,
including the history of present illness It’s all about creating a supportive environment,
setting the stage for effective treatment. Psycho education was done about client
problem with client and informants.

2nd Session (45 to 60 minutes)

Typically continue to build on the progress made in the first session. delve
deeper into the client thoughts, emotions, and behaviors, exploring the underlying
causes of the depression more extensively. Discuss about test that was administer in
next visit.

3rd Session (90 minutes)

In this session first review what was discussed in previous sessions to create a
comfortable atmosphere. Then, explain the purpose of the Beck Depression Inventory
(BDI) test, which measures the severity of depression. After that, administer the BDI,
guiding the client through the questionnaire while providing support. When client
completes it, score and interpret the results, discussing what they mean in relation to
her feelings. then plan the next steps in treatment based on the results and the client
need in next session.

4th Session (60 minutes)

In the fourth session begin by reviewing the results of the Beck Depression
Inventory (BDI) from the previous session.

Discuss her feelings about the results and explore any insights or reactions the
client had. Then focus on specific symptoms or areas of concern highlighted by the
Beck Depression inventory (BDI) working collaboratively with the client to set goals
for treatment. Introduce therapeutic techniques or coping strategies tailored to the client
 15

needs. This technique include mindfulness exercise and behavioral activation were
discuss and applied.

5th Session (50 minutes)

Continue of applied technique tailored to her specific needs and progress in

managing her major depressive episode. Behavioral activation to address negative
thought patterns, to increase engagement in positive activities. Mindfulness and
relaxation techniques practices to enhance self-awareness.

For further treatment of a client with a major depressive episode, with applied
techniques also Deep breathing and meditation techniques were suggested Additionally,
exploring medication options. Encouraging lifestyle changes such as regular exercise
can improve overall well-being.

6th Session (60 to 65 minutes)

In which session main focus on summarizing the progress was made throughout
the session process. reviewing coping technique. Aims to empower her to maintain her
mental well-being independently and apply the skills learned through technique
effectively in her daily life.

Provide further support in managing her major depressive episode suggest

technique, this includes deep breathing and meditation or creating a personalized self-
care plan tailored to client specific needs and preferences. Also discussed importance
of continuing process or seeking additional support if needed to maintain her mental
health progress.
 16

Case Summary

Client name was AR. Client was 23 years old male. He came with the presenting
complaints of excessive emotionality anger and outbursts. Six sessions were conducted.
Psychological assessment was done on informal level which comprised of history
taking, behavioral observation and mental state examination of presenting complaints,
and dysfunctional thought record. According to DSM-5-TR the client was suffering
from borderline personality disorder (BPD)301.83(F60.3) because he had the
complaints of unstable relationships, fear of loneliness, irrational decisions, identity
disorder, persistent feelings of emptiness, intense anger and self-harm

Formal assessment was done by using the McLean Screening Instrument for
Borderline Personality Disorder (MSI-BPD)

Find the structured environment challenging and sensory issues bother him
following instructions and communicating effectively also be tough for his during
sessions. mindfulness technique, emotional regulation technique and cognitive
restructuring technique applied as a management plan. This management plan helps to
improve quality of client life.
 17

Introduction of Disorder

Borderline Personality Disorder (BPD) is a complex mental health condition

characterized by emotional instability, impulsive behaviors, and difficulties in
maintaining relationships. Individuals with BPD often experience intense mood swings,
fear of abandonment, and issues with self-identity, which can lead to self-harm and
other risky behaviors. The disorder is frequently associated with trauma or unstable
environments during childhood. (Gunderson, 2011).

People with BPD have an intense fear of abandonment and have trouble
regulating their emotions, especially anger. They also tend to show impulsive and
dangerous behaviors, such as reckless driving and threatening self-harm. All of these
behaviors make it difficult for them to maintain relationships
 18

Identifying Information

Name AR

Age 23

Gender Male

No of Sibling 04

Birth order. 1st

Education BA

Occupation. Security guard

Marital status unmarried

Religious. Islam

No of session. 06

Source and Reason of Referral

The client was brought to the hospital by family for treatment of his problem
and assessment to manage Then the client was referred by psychiatrist to trainee clinical
psychologist from outpatient department for psychological assessment and
management.
 19

Table 2.1

Presenting Complaints reported by Client and informants

‫دوراین‬ ‫ت‬
‫العام ہ‬

‫ابرہامہ‬ ‫ذجابیتدعمااکحتس ہم‬

‫ابرہامہ‬ ‫کشم‬
‫رےتشربرقارہرےنھکںیم ہ‬

‫ااھٹرہامہ‬ ‫ف‬
‫اہنتئاکوخ ہ‬

‫ااھٹرہامہ‬ ‫ریغبوسےچہلصیفرک ہان‬

‫ابرہامہ‬ ‫انشتخںیمللخ‬

‫ابرہامہ‬ ‫وسحمسرکاتہ‬
‫ہ‬ ‫ارثکاخیلنپ‬

‫ااھٹرہامہ‬ ‫دشدیہصغرکاتہ‬

‫ابرہامہ‬ ‫وخد ہوکاصقنناچنہپاتہ‬

‫ابرہامہ‬ ‫ااہتنئذجابیتوہاج ہان‬

Initial Observation

AH was entered the room, wearing dark colored pants and a black shirt with
brother and father. His hair was well done‫ ۔‬There was a look of anxiety in his eyes. His
behavior was unbalanced, he was shaking his hands repeatedly. His reaction was highly
emotional.

History of Present Problem

The problem started almost 12 to 18 months ago. he was a security guard of

private school during his duty leads to intense emotions, unstable relationships, and
impulsive actions. Often struggle with feelings of emptiness and fear of abandonment.
His father was an army retiree and his mother is a house wife‫ ۔‬It is bigger than all the
siblings in its house.
 20

According to his father During his duty, he often used to get into fights, anger
used to consume him a lot since childhood, but now for some months, his behavior
became mor‫ک‬e severe, he used to fight outside, even at home, he gets angry because of
this behavior, he was expelled from the school. Due to which he started to be very
worried and his behavior was setting worse day by day.

Background Information

Personal History

The client was 1st among siblings in birth order and 1 year older than his younger
brother. Due to immediate birth of brother. He reported that he was never loved. He
born through normal delivery and his weight at time of birth was 2KG he was
underweighting and was kept in nursery to a week under supervision. His first cry was
time appropriate. Client shows no any type of sexual history. Client reported no drug
abuse as well as no forensic history

Education History

The schooling of client started at the age of 5 in a government school. He was

an average student and had extreme difficulties in science subject throughout his
education. He didn’t make any friends except one friend in college with whom his bond
broken later due to his extreme attachment to his that led to fights over minor things
and so much expectations. After doing BA, the client couldn’t continue his education
because as he was the eldest in the house and his father who was now staying at home
after retirement from army, the client started working after BA The client himself had
no particular interest in studies

Family History

Client belonged to a middle class, Muslim family. His father was 51 years old and doing
job in army before while his mother was 49 and was a house wife. His relationship with
each parent was not so good. There was a big communication gap between his and
parents. His relationship was particularly conflicted with siblings. His parents show
little or no interest in his matters and pay attention on younger siblings. Mother was
authoritative figure of house. Client parents’ relationship was also not good.
 21

Pre-Morbid Personality

Client father said that his behavior was angry since childhood, so he does not
become anything special with his younger siblings.

Even as a child, he reported lack of happiness and enjoyment in childhood. He

said that he never liked his family or household and he do not like to ask from them for
anything that why he started earning for own self. He never interests in made friends
he had just one friend in college. He reported his extreme aggressive nature because
he gets hurt by people minor actions since his childhood, it although got intense during
teenage.

History of Medical Illness

According to client family, his behavior was angry since childhood, but he was
normal in every way, he used to do all his work by himself. He knew well about himself.
He also knows and treats his family members well. His behavior was angry, but he gets
angry in certain situations, such as when he does not want to do something. But these
changes in his attitude had been fighting everywhere for the last nine to ten months.
Self-deprecating, highly emotional and lacking in self-awareness. Unstable
relationships

Assessment

Informal Assessment

• History Taking
• Behavioral Observations
• Mental State Examination

Formal assessment

• McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD)

Informal Assessment
 22

History Taking. Involves collecting detailed information about a client’s

background, including personal, family, and medical history, to understand their issues
better and guide treatment (Leod, 2013).

Determine the predisposing factors that caused the psychological presenting

complaints in the client, a clinical interview was conducted. As this interview included
so much sensitive information to client’s mind, it was completed with 2 breaks in one
and half hours. The interview revealed so much information about childhood abuse,
family issues, strained housed environment, lack of support, discrimination between
siblings and comparison with others.

Behavioral Observation. Behavioral observation is a technique used in

psychology to systematically watch and record an individual’s behavior in various
settings. This method helps in assessing behaviors, understanding patterns, and
identifying triggers (Kazdin, 2017).

Behavioral Observation is a primary technique to decipher non-verbal cues

through body language and expressions of the client during the interview. His
vocalization, verbalization, facial expressions, temperament and general appearance
was observed.

The client was 22 years old with 5.4 feet height and 48KG weight that was
extremely low according to Body mass index. He had a nervous feeling as depicted
though continuous pressing of fingers. He did not cooperate during history taking with
little reluctance in disclosing information. Often show emotional instability, with rapid
mood swings and intense reactions. Communication is dramatic, and impulsive
tendencies surface, along with discussions of self-harm.

Mental State Examination. The Mental State examination (MSE) is an

important part of the clinical assessment process. Mental State examination (MSE) is a
structured assessment of an individual cognitive and emotional state, focusing on
aspects like appearance, behavior, mood, and thought processes, which aids in
diagnosis and treatment (Bickley & Szilagyi, 2017).

Appearance. Client was 23 years old. He was looking confused he wears pent
shirt and his hair was well done His reaction was highly emotional.
 23

Attitude. He shows different attitudes during the history-taking process. He was

often had intense emotions that change quickly, leading to feelings of anger or sadness.
He had feeling judged.

Behavior. He displays variety of behaviors during history-taking process that

complicate communication. He often experiences rapid shifts in emotions, leading to
intense reactions such as anger, sadness, or anxiety, which disrupt the flow of the
discussion.

Speech. He speak quickly, as if trying to convey a whirlwind of thoughts and

feelings. His sentences fragmented or disjointed, jumping from one subject to another
without clear transitions. He uses vivid and descriptive language to express his emotion,
for instance, express feelings like, “I just feel so lost. One minute, I’m laughing, and
the next, I’m crying. It’s exhausting,” showcasing the depth and complexity of his
emotional state.

Mood. Mood was quite variable and intense. He was experiencing rapid shifts
in mood, often swinging from feelings of extreme happiness or excitement to deep
sadness or anger within a short period.

Thought Process. He was experiencing rapid shifts in thoughts and feelings,

leading to confusion or difficulty in focusing on the conversation. His thoughts
influenced by strong emotions, causing to jump from one topic to another or to interpret
situations in a black-o white manner, where things was either all good or all bad.

Thought Content. Express fears of abandonment, leading to thoughts that

others will leave his or that they were unworthy of love and support. Create a
preoccupation with relationships, where he was idealizing someone one moment and
then devalue them the next. Had thoughts related to self-harm.

Orientation. Orientation refers to the awareness of oneself in relation to time,

place, and situation.
 24

Orientation of Person

‫وہ‬
‫تآئہ ہ‬
‫آپہکہےکہاس ہ‬k2

‫ں‬
‫ںیمویکںاتبؤ ہ‬

Memory

Recent Past Memory

‫ہہآپلکاھکںےھت‬

‫رھگ‬

Recent Memory

‫ںیھ‬
‫ہآپہاسہوقہاہک ہ‬

‫اتپسہل‬

General Information

‫ئ‬
‫تفہہےکہدونںہےکہانمہاتب ہ‬

‫لگنمدبھ‬

Perception. He had emotional instability and impulsive behaviors, and it does

not typically include hallucinations or delusions

Insight. Client had limited insight into his condition. Struggling to understand
how his thoughts, feelings, and behaviors affect. recognize the patterns of emotional
instability or impulsivity in his live which hinder his ability to seek help or make
changes.
 25

Formal Assessment

The McLean Screening Instrument (Lean et al., 2003). The McLean

Screening Instrument (MSI-BPD) is a brief self-report tool designed to identify
symptoms of borderline personality disorder. It includes questions that assess emotional
instability, impulsivity, and interpersonal difficulties (Lean, et al. 2003).

The McLean Screening Instrument for Borderline Personality Disorder (MSI-

BPD) is a commonly used 10-item measure to screen for borderline personality disorder
(BPD). Mary Zanarini, EdD, and her colleagues at McLean Hospital developed this
paper-and-pencil test based on BPD diagnostic criteria. Listed in the Diagnostic and
Statistical Manual of Mental Disorders (DSM). It has also demonstrated sensitivity and
specificity for detecting borderline personality disorder when a score of 7 is used as the
cutoff.

Table Showing Scores Obtained in The McLean Screening Instrument for

Borderline Personality Disorder (MSI-BPD).

Table 2.2

Ranges Client Score Level

0-3 Mild
4-6 Moderate
7-9 08 Severe
10 Extreme

Interpretation. The result of test Score 8 show high symptoms associated with
borderline personality disorder (BPD) traits. This score indicates that the client
experiencing emotional instability, relationship difficulties, and issues with self-image.

Diagnosis

According to DSM-5-TR the client was suffering from borderline personality

disorder (BPD)301.83(F60.3) because he had the complaints of unstable relationships,
fear of loneliness, irrational decision’s identity disorder, persistent feelings of
emptiness, intense anger and self-harm.
 26

Client Prognosis

Client was feeling strong desire for relief from intense emotions and instability
in his live. Motivate his to engage in therapy. A trusting connection is essential, as it
provides a safe space for explore his feelings.

Intervention Plan

Short Term Goals

• Rapport building was done to develop a trust worthy relationship. It was also
done to make a strong and healthy therapeutic relationship.
• Psycho-education also was done. it helps client to understand his diagnosis,
reduces stigma, and increases self-awareness.
• Identify and articulate specific environmental triggers that contribute to
emotional dysregulation within the next two therapy sessions.
• Help his to focuses on become more aware of how his surroundings impact his
emotions and behaviors.
• Develop understanding to learn the key characteristics and symptoms of
borderline personality disorder to enhance his understanding of diagnosis.

Long Term Goals

• Continuation and implementation of short-term goals.

• Follow up sessions conducted.
• Focus on to achieving greater emotional stability of his thoughts and behavior.
• Develop to improved interpersonal relationships over the course of session
process.
• Guide his to consistently using learned coping strategies to manage emotional
distress.
• Aiming to reduce the frequency and intensity of emotional crises.
• Develop healthier communication skills and boundaries in relationships.
• Increase self-awareness by identifying pattern in thoughts and behavior, which
• Leading to improve decision making and responses.
 27

Treatment

Techniques Applied

• Rapport Building
• Psycho Education
• Mindfulness Technique
• Emotional Regulation
• Cognitive Restricting Technique

Rapport Building. Rapport building is a technique in therapy that focuses on

creating a trusting and empathetic relationship between the therapist and client. It
involves active listening, genuine interest, and a safe environment, which enhances
communication and therapeutic effectiveness (Rogers, 1961).

Psycho Education. Psychoeducation is a therapeutic approach that educates

individuals about their mental health conditions, enhancing understanding and coping
skills. It helps improve treatment adherence and reduces stigma (Mueser & Gingerich,
2006).

Mindfulness Technique. Mindfulness techniques emphasize being present and

aware of thoughts and feelings without judgment, which can enhance emotional
regulation and well-being (Linehan, 1993).

Emotional Regulation. Emotional regulation technique focuses on

understanding and managing intense emotions through skills like identifying emotions,
increasing positive experiences, reducing vulnerability, and using opposite action when
necessary. (Linehan, 1993).

Cognitive Restructuring Technique. Cognitive restructuring technique helps

individuals identify and challenge negative thoughts to change their emotional
responses. By evaluating evidence for these thoughts and replacing them with more
realistic ones, it reduces anxiety and depression (Beck, 2011).

Technique Suggested

• Emotional Regulation Skills

 28

• Support Net Work

Emotional Regulations Skills. Emotional regulation focuses on understanding

and managing intense emotions through skills like identifying emotions, increasing
positive experiences, reducing vulnerability, and using opposite action when necessary.
These techniques help individuals respond more effectively to emotional challenges
(Linehan, 1993).

Recommend client to create a feeling diary where he cannot down his emotional
experience, triggers.

Support Network. Encourage client to engage with support group and peer
network where he can share experience and learn from others.

Recommendations

• The client should come for the follow up sessions for the further management
of his problems to cope fully with his problem.
• Encourage his to Focusing on the present moment discussion of current
feelings rather than delving deeply into past traumas.
• Self-reflection be promoted through open-ended communication allowing the
client to explore his thoughts without judgment.

Limitations

• Emotional dysregulation, where client experience intense and fluctuating

emotions that disrupt focus.
• Fear of abandonment, leading to anxiety and potential testing of the therapist
commitment and interpersonal challenges that cause conflicts or
misunderstandings.
• Client had exhibit splitting, seeing the therapist in extremes, and had engage in
impulsive behaviors that distract from therapy.
• Sometimes Resistance to treatment also occur.
 29

Session Report

1st Session (60 to 70 minutes)

Rapport Building was maintaining to Creating a safe and supportive

environment to help the client feel comfortable to sharing his experiences. Conduct
comprehensive assessments to help determine the problem Initial assessment include
history taking and initial observation that evaluate his symptoms, behaviors, and
emotional patterns, gathering information and any previous treatments. Discuss
confidentiality and ensuring client understands his rights within the therapeutic
relationship. Explore the client immediate concerns and challenge

2nd Session (50 minutes)

In the second session, usually builds on what was covered in the first session.
Provide education about problem to help the client understand his experiences better.
Start by reviewing the previous discussion and checking in on how he had been feeling.
This session includes further assessment, where asks more detailed questions about his
symptoms, emotions, and relationships to get a clearer picture of his situation and gain
deeper understanding of his situation.

3rd Session (55 minutes)

The session began by reviewing the client previous session and telling the client
that a test w applied to confirm the client problem. Before conducting the test, it was
important to create a calm and focused environment. This included minimizing
distractions, ensuring adequate lighting, and staying in a comfortable space.

In this session, administers a test that closely examines the client problem. The
therapist was fully guided through the process so that the client knew what to expect.
After the test was over, the results were discussed.

4th Session (45 minutes)

This session was started with the result of the client previous session. After
discussing the results, the client was told that some techniques were applied to solve
client problem. The main focus was on commonly applied techniques. Included in these
 30

techniques Mindfulness techniques and emotion regulation help clients understand

emotions and develop effective coping strategies during sessions.

5th Session (50 minutes)

This session was overall depending upon applied technique. This session
combines the techniques previously applied, cognitive restructuring technique with
mindfulness techniques and suggested emotional regulation skill this involve This
approach helps clients manage his emotions and control stress and anxiety more
effectively.

6th Session (70 minutes)

This session was about reviewed the applied technique skills. The therapist
encouraged him to continue using his coping strategies and mindfulness practices,
which allowed him to see better improvements in problem, while setting goals for
future, as well as therapist discuss suggested technique, suggest client to create a feeling
diary where he cannot down his emotional experience and triggers. Encourage him to
engage with support group and peer network where he can share experience and learn
from others.

Therapist acknowledges the client journey and progress, encouraging to

continue using his skills in the future. The session concludes with best wishes as the
client prepares to move on to the next steps in life
 31

Case Summary

Z.A was 25 years old male client came to the psychiatry department with
presenting complaints of fatigue aggressive behavior, suicidal ideation hopelessness
and disturbed family relationship.

Informal assessment including history taking, behavioral observation and

mental State examination were conducted. For formal assessment Alcohol use disorder
identification (AUDIT) test was applied. According to DSM 5-TR criteria client was
diagnosis with alcohol use disorder 303.90 (F10.20).

Sixth sessions were conducted, in which motivational enhancement technique,

acceptance and mindfulness technique were applied as a treatment or management plan.
The management plan of the client helped to control and treated client presenting
problem. Client appearance was good. The client was much more cooperative with for
recovery from this problem. The session process helped much in improving behavior
and problem of client.
 32

Introduction of Disorder

Alcohol use disorder (AUD) is a chronic illness in which individual can’t stop
or control their drinking even though it’s hurting individuals’ social life, their job, or
their health. Alcohol Use Disorder (AUD) is a condition characterized by an
individual’s inability to control their alcohol consumption, leading to significant health,
social, and economic consequences. This disorder can manifest through a range of
symptoms, including cravings, tolerance, and withdrawal, and can affect anyone
regardless of age or background.

Alcohol use disorder is one of the most commonly diagnosed addictive

disorders. Alcohol use disorders affect 4%–9% of the US population, with the specific
rate depending in part on age at diagnosis (APA, 2013) The interplay of genetic,
psychological, and social factors contributes to its development, making it a
multifaceted issue that requires comprehensive treatment strategies (Substance Abuse
and Mental Health Services Administration (2020) Alcohol not just problematic use, is
associated with involvement in other risk-taking behaviors (Kelly et al., 2005).
 33

Identifying Information

Name ZA

Age 25

Gender Male

Father’s Occupation Labor (Deceased)

Mother’s occupation House Wife

No. of Siblings 05

Birth order 2nd

Number of Sessions 05

Referral Source Family

Source and Reason of Referral

Client elder brother referred him to hospital due to client demand of money for
drug, bleeding from nose and throwing things for not getting money and for treatment
or management of client problem.
 34

Presenting Complaints

Table 3.1

‫ین‬
‫دورا ہ‬ ‫ت‬
‫العام ہ‬

‫اپچناسل‬ ‫سےسہدنپرہابر‬
‫نںیمد ہ‬
‫رشابیکدقمارہد ہ‬

‫اچراسلہ‬ ‫نںیمیئکہابر‬
‫اگیلولگچد ہ‬

‫اپچناسل‬ ‫نںیمیئکابر‬
‫ہصغےکاسملئد ہ‬

‫د ہواسل‬ ‫ت‬
‫وخدیشکےکایخال ہ‬

‫د ہواسل‬ ‫اکیبرنپ‬

‫نیتاسل‬ ‫رفتیحیرسرگایمںمک‬

‫اچراسلہ‬ ‫ی‬
‫انادیم ہ‬

Initial Observation

The client was 25 years old male with an untidy appearance and entangled hair.
He was not willing to communicate initially. He was continuously itching his arms.
Client was an introvert and his speech was unintelligible. It was difficult to make him
speak. After asking his name and few general things about weather, his school
memories and favorite food, he felt little comfortable. He didn’t socialize much and
was not maintaining an eye contact. He was so slow in his movements and his hands
were shivering. He was gripping the glass with a firm grasp.

History of Present Problems

Client brother referred him to hospital because he was consuming a lot of

alcohol and when he did not find money to buy alcohol, he beat himself and throw
things away. Client abuses others and throw thing at everyone. He was showing
aggression and blamed his family to be enemy. When he tried to quit drug abuse, he
 35

became even more aggressive. He often stayed outside the house with his friends for
many days. The client was losing weight and was becoming thinner.

The client visited many hospitals and he stayed in one of rehabilitation center
for some time but had to quite due to financial issues. The client first indulged in drug
intake 5 years back after his father death. After his father death, he quitted studies and
started working in a nearby shop. There he started alcohol intake due to peer pressure.
He was a gentleman and respected his mother so in start of drug intake, on her request
he wanted to quit alcohol intake but his condition got worse. Now to get alcohol, he
threw things and makes fuss in the home. There was no psychological illness reported
in any other member of family.

According to the client, alcohol was his way to escape from painful life. He said
that he wanted to quit but he ends up worrying about life and its adversities. He loved
his brother and upon his requests he agreed to visit the hospital again.

Background Information

Personal History

The client was 2nd among siblings in birth order. He was born through normal
delivery and weighed appropriate at time of his birth. First cry after birth was time
appropriate. The client had asthma since childhood He covered his development
milestones age appropriately No sexual disorientation or abused was reported. The
patient reported no forensic history.

Education History

The client was good in studies. He passed his metric exams from a government
school but due to father death he stopped studying and worked in nearby shop. He was
an average student and he was particularly interested in arts. He like to make painting
and liked singing.

Family History

The client belonged to a lower-class family. He had 5 siblings. He was 2nd one.
His father died when he was 18. He quitted studies after that. His mother was house
 36

wife and she was uneducated. Client late father worked as a labor. He had good
relationship with his family. The environment of the house before his father’s death was
good despite poverty.

Client was unmarried. His relationship with mother was complicated after drug
abuse due to continuous fighter in the house. He regretted disrespecting his mother and
reported that he was not in his own control. His relationship with brother was although
better because treated him with love and care.

The authoritative figure of the house was his father and after father death his
mother and elder brother took charge of the house. There was no psychological illness
reported in any member of the family.

Drug Abuse

The client reported intake of alcohol. He reported that he liked weed but it
worsens his symptoms of asthma that he had from childhood.

Pre-Morbid Personality

The client was an obedient child and an average student. He was always an
introvert so had only few friends. After quitting studies, he lost his friends due to no
connection with them anymore. The change in company affected him in many ways
including making him learn foul language and drug intake as well. He was so good in
arts, painting and music.

History of Medical Illness

The client did not have any history of psychiatric illness in his family. He was
born through normal delivery and weighed appropriate at time of his birth. First cry
after birth was time appropriate. The client had asthma since childhood. He covered his
development milestones age appropriately.

Psychological Assessment

Psychological assessment was done at both formal and informal levels.

 37

Informal Assessment

• History taking
• Behavioral Observations
• Mental State examination

Formal Assessment

• Alcohol use Disorder identification test

Informal Assessment
History Taking. History taking in psychology involves collecting detailed
information about individuals background, including personal, family, and medical
history, to understand their issues better and guide treatment (Leod, 2013).

The client felt worthless, after his father death he quitted studies but he wanted
to become an officer in some prestigious department. He reported that it was money to
be blamed that made him ruin his life. He also reported that he wanted to end his life
and he felt like a burden on his family and a source of sorrow for his mother. The client
showed a will to quit drugs.

Behavioral Observation. Behavioral observation is a technique used in

psychology to systematically watch and record an individual’s behavior in various
settings. This method helps in assessing behaviors, understanding patterns, and
identifying triggers (Kazdin, 2017).

The client was 25 years old man with 60 KG weight and 5.9 height. The client
hands were shivering and his movements were slow. His comprehension of the speech
was intact but he had slow speech. His orientation of time, place and date was also
normal. He had an insight of the issue and his will to amend the issue was high.

Mental State Examination. Mental State examination (MSE) is a structured

assessment of a patient’s cognitive and emotional state, focusing on aspects like
appearance, behavior, mood, and thought processes, which aids in diagnosis and
treatment (Bickley & Szilagyi, 2017).
 38

Appearance. The client was a twenty-five-year-old man‫ ۔‬He was wearing a

brown suit which was perfectly clean and pressed. His hair was looking messy. His
height was two and a half feet.

Behavior. He was moving his trunk to and fro sometime he began to shake his
legs. Display changes in behavior, such as mood swings, secretive behavior regarding
his drinking habits.

Speech. His volume of speech exhibit slurred speech, difficulty articulating

clearly, seem disoriented in his conversations.

Mood. His mood was mostly irritated. Exhibit erratic actions, mood swings,
secrecy about his alcohol consumption.

Thought Process. Experience impaired thought processes, such as difficulty

concentrating, memory problems, or distorted thinking pattern. Also, suicidal ideation
is present

Thought Content. There were thoughts of committing suicide in his mind.

client had negative or distorted beliefs about himself, his relationships, or future. His
thought patterns contribute to feelings of hopelessness, guilt, or worthlessness.

Orientation. Orientation refers to the awareness of oneself in relation to time,

place, and situation. ‫ہ‬

Orientation of Person

‫پکےکاستآئ‬
‫آ ہ‬

‫اھبئےکاست‬

Memory and Concentration. Experience impairments in memory function.

Alcohol interferes with the brain’s ability to form new memories and retrieve existing
one.
 ‫‪39‬‬

‫‪Recent Past Memory‬‬

‫ھت‬
‫پلکہاہکںہ ہ‬
‫آ ہ‬

‫اھبئےسوپھچےل‬

‫‪Remote Memory‬‬

‫گ‬
‫ئ ہ‬
‫ئابتہاتب ہ‬
‫پانپہوکسلہیکہوک ہ‬
‫ایکہآ ہ‬

‫ںیہناھت‬
‫ریماوکسلںیموکئدوتس ہ‬

‫‪Concentration.‬‬

‫یئ‬
‫اسہرتیتہےسہدرہا ہ‬

‫ت‬
‫اہپڑ‪،‬ہرحصاہگنجہ‪،‬ہاباغ ہ‬

‫اہپڑ‪،‬گنج‪،‬اباغت‬

‫‪General Information Intelligence.‬‬

‫ت‬
‫اپچنہاورہدوہےنتکہوہ ہ‬

‫ایک‬
‫ہچبوہ ہ‬
‫ںیمےنںیہناتبانںیموکئ ہ‬

‫یہ‬
‫پےکہرھگہںیمہےنتکہولگہرتہہ ہ‬
‫آ ہ‬

‫ریمےاوبںیہنابیقمہبسنہباھبئاو ہروادلہ‬
 40

Perception. Experience alterations in how perceive the world around him. This
manifest as distorted sensory experiences, such as seeing things that was not there
(hallucinations) or misinterpreting sensory information but during history taking
process no sign of hallucinations and delusions. This sign appears when he intake
alcohol drug in much quantity.

Insight. He was recognizing the negative consequences of his alcohol use and
want to seek help.

‫تچ‬
‫پانپہاسہلئسمہےکہابرےہںیمہایکہوس ہ‬
‫آ ہ‬

‫وہجےستہبرشدنمہوہ‬
‫ںیماس ہ‬

Formal Assessment

Alcohol Use Identification Test (Babor et al., 2001). The Alcohol Use
Identification Test (AUDIT) is a widely used screening tool designed to identify
individuals who may have problematic drinking behaviors. Developed in the early
1990s, the AUDIT consists of ten questions that assess alcohol consumption, drinking
behaviors, and alcohol-related problems. The test is simple and can be administered in
various settings, including healthcare facilities, community programs, and research
contexts. Respondents answer questions related to their drinking patterns, such as
frequency and quantity of alcohol consumed, as well as any negative consequences they
may have experienced due to their alcohol use. The AUDIT is beneficial because it
provides a quick and effective way to identify individuals at risk for alcohol use
disorder.

Table 3.2

Range Client Score Level

0-7 Low
8-15 Moderate
16-19 High
20-40 31 Severe
 41

Interpretation. Alcohol Use Identification test was administered in which

client had scored 31 that was evident of extreme level of risk.

Diagnosis

According to DSM 5-TR criteria client was diagnosis with alcohol use disorder
303.90 (F10.20).

Client Prognosis

The prognosis of client was good because he motivated for treatment.

Intervention Plan

Short Term Goals

• Building trusting and effective environment

• Identifying and address any environmental trigger that led to alcohol use
• Guide to Attend session or support group sessions regularly to address
underlying issue.
• Learn to manage cravings and triggers effectively.
• Focus on making progress towards recovery and well-being during each
session.
• Participate in counseling to explore reasons for alcohol misuse
• Learn coping skills to manage triggers that lead to drinking.
• Create a structured plan for progress towards recovery.

Long Term Goals

• Implementation of short-term goals

• Working on follow up session process
• Achieve sustained sobriety to maintain a healthy lifestyle.
• Improve overall mental and physical health through ongoing sessions and self-
care.
• Develop effective relapse prevention strategies to avoid returning to alcohol
use.
• Make necessary lifestyle changes to support long-term recovery.
 42

• Build a strong support system for continued encouragement and

accountability.
• Working on applying and implementation of technique.

Treatment

Techniques Applied

• Rapport Building
• Psycho Education
• Motivation Enhancement
• Acceptance and Mindfulness

Rapport Building. Rapport building is a technique in therapy that focuses on

creating a trusting and empathetic relationship between the therapist and client. It
involves active listening, genuine interest, and a safe environment, which enhances
communication and therapeutic effectiveness (Rogers, 1961).

Psycho Education. Psychoeducation is a therapeutic approach that educates

individuals about their mental health conditions, enhancing understanding and coping
skills. It helps improve treatment adherence and reduces stigma (Mueser & Gingerich,
2006).

Motivation Enhancement. Motivational enhancement techniques aim to

increase a person’s motivation to change behaviors, especially regarding substance use,
often using strategies like Motivational Interviewing to explore ambivalence and
support self-efficacy (Miller & Rollnick, 2013).

Acceptance and Mindfulness. Acceptance and Mindfulness technique helps

individuals accept their thoughts and feelings without judgment, promoting emotional
regulation and reducing stress, which aids in managing behaviors like alcohol use
(Zinn, 1990).

Techniques Suggested

• Withdrawal Therapy
 43

Withdrawal Therapy. Withdrawal therapy techniques help individuals manage

symptoms when stopping substance use, utilizing medical detox, counseling, and
behavioral therapies to support recovery and prevent relapse (Connor, 2003).

Limitations

• During a session client experience limitations that impact his treatment

process:
• Emotional Instability
• Physical Health Concerns

Recommendations

• Open Communication
• Active Participation

Open Communication. Encourage open and honest communication about his

struggles, thoughts, and feelings regarding alcohol use. This help in addressing
underlying issues effectively.

Active Participation. Engage actively in therapy sessions by being present,

listening attentively, and participating in activities or exercises suggested.

Stay committed to his treatment plan and reach out for help whenever needed.
You’re not alone in this process, and support is available to assist you every step of the
way
 44

Session Report

1st Session (60minutes)

In the first session begins with a comprehensive assessment to gather

information about the client history of alcohol use, including patterns, frequency, and
any adverse effects experienced. Building rapport to creates a safe and non-judgmental
environment to foster open communication. Psycho education was provided, offering
insights into alcohol use disorder and its implications.

2nd Session (45 minutes)

In the second session builds on the foundation established in the first session.
By reviewing any challenges, the client experienced since his last meeting. This
includes discussing any situations where the client felt tempted to drink and how he
was managed those urges. It was discussed with the client and informants that some
tests were applied to confirm his problem.

3rd Session (60 to 65minutes)

The session started with a discussion on how to apply the test Before
administering the test, a comfortable and nonjudgmental environment was created that
included explaining the purpose of the test, ensuring confidentiality, and encouraging
honesty in responses. then apply drug abuse screening test and alcohol use disorder
identification test (AUDIT) to confirm about problem. then client provide details about
his alcohol consumption and related behaviors. After the test was completed, results
were shared with the client and informants to assess alcohol use. Based on the score,
recommendations for further support or treatment provided, along with an opportunity
to ask questions.

4th Session (50 minutes)

Review about previous session any concerns and challenge. In this session basic
focus on applied technique involves Motivation enhancement technique, Acceptance
and Mindfulness technique was applied for treatment and management of client
problem. Encourage client to daily practice applied technique for betterment of
problem.
 45

5th Session (45minutes)

This session begins with a review of his experiences since the last session,
discussing successes or challenges he faced in managing his recovery. Discussion about
previous technique was applied and practice introduce relapse prevention technique
withdrawal technique was suggested for ongoing recovery, By the end of the fifth
session, the aim was to reinforce his motivation and commitment to his recovery plan,
ensuring he feel equipped to handle challenges moving forward.

6th Session (65 minutes)

In this session the main focus on consolidating all the progress made during
process and preparing the client for ongoing recovery. Start by reviewing the key
milestones the client had achieved by applied technique

This session includes a discussion about the client feelings regarding

completing process. address any concerns or anxieties he had been about maintaining
sobriety moving forward. Provide reassurance and remind the client of his strengths,
to handle future challenges. Help him to develop a personalized aftercare plan. This
plan includes regular check-ins with Applied technique continued practice of coping
strategies. The session would conclude with a positive affirmation of his journey,
celebrating his commitment to recovery and encouraging him to stay connected with
his support network and working on follow up techniques as he transitions into his new
phase of life.
 46

Case Summary

Client was 9-year-old boy, contacted due to the presenting complaints of

Shaking hands and legs, Attention Deficit Mutism, Study problems, not getting the task
done, and difficulties in organization. 6 sessions were conducted.

According to DSM 5-TR 314.01(F90.2) client was suffering from severe

symptoms of attention deficit hyperactivity disorder (ADHD) because he had
complaints of Shaking hands and legs Attention deficit bullying mutism study
problems, not getting the task done difficulties in organization

Client was assessed using informal as well as formal assessment including

history taking, behavioral observation and mental state examination of presenting
complaints while for formal assessment. role playing technique, reinforcement
technique and physical activity scheduling technique applied as management and
treatment plan. The sessions process helped much in improving attention deficit or
hyperactive behavior of client. The client was not giving much attention on things.
 47

Introduction of Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental

disorder characterized by persistent patterns of inattention, hyperactivity, and
impulsivity that can significantly impact daily functioning and development. It
typically emerges in childhood and can persist into adulthood, affecting various aspects
of life, including academic achievement, social relationships, and occupational success.
Symptoms can vary widely among individuals, leading to difficulties in maintaining
attention, organizing tasks, and controlling impulses. it is estimated to affect around 5%
of children globally (Barkley, 2015).

Attention-Deficit/Hyperactivity disorder (ADHD) are inattention, hyperactivity

and impulsivity (American Psychiatric Association 2000) In individuals with ADHD,
these behaviors are present for at least six months at level higher than is typical for their
stage of development, are present early in life (currently defined as before age 7), and
cause impairment Currently three sub-types of ADHD are recognized:

• Primarily Inattentive
• Primarily Hyperactive impulsive,
• Combined Type

The inattentive subtype consists of individuals who exhibit inattentive

behaviors but not hyperactive/impulsive behaviors, whereas the hyper-active/impulsive
subtype consists of the reverse, and individuals with the combined subtype have both.
 48

Identifying Information

Age 09

Gender Male

Class 03

Father’s Occupation Businessman

Mother’s Occupation Banker

No. of Siblings 03

Birth order 02

Family System Nuclear

Referral Source Mother

Session. 06

Reason and Source of Referral

Client mother brought him for treatment as he was not performing well at
school. He was attending more than one tuition but he hardly passed the exam. He did
not respond to instruction and sometimes he got so angry that he broke things and
involved in vandalism. Client was only attached to his mother and listened only to her.
Client took a lot of time to complete a simple homework and did not respond to tutor.
 49

Presenting Complaint

Table 4.1

Presenting Complaints by Client and Informant

‫ین‬
‫دورا ہ‬ ‫ت‬
‫العام ہ‬

‫نیتاسل‬ ‫اہتاوراپؤںنلہہ‬

‫اچراسلہ‬ ‫مک‬
‫وتہجںیم ہ‬

‫اچراسلہ‬ ‫ی‬
‫ڈنغہرگد ہ‬

‫نیتاسل‬ ‫ی‬
‫اطمہعلںیمزمکور ہ‬

‫ل‬
‫نیتاس ہ‬ ‫اکملمکمہنرکان‬

‫اچراسلہ‬ ‫ت‬
‫میظنتںیمالکشم ہ‬

Initial Observation

Client was 9 years old child with a neat and clean appearance. Client appeared
serious angry face. He kept moving his leg hitting the table again and again. He looked
so indifferent to any command or instruction. He was not answering anything and
seemed so angry for the session. It took some time to even ask his name but he was
reinforced for rewards by his mother to answer. He seemed being a little cooperative.

History of Present Illness

Client mother said that client was a premature baby and his maternal uncle also
had learning problems. Client younger brother was also a premature baby but he was
too young for saying that if he had similar issues too. Client older sister was 15 year
and client was quite good in studies. Client was not much social. When he was admitted
to school, he did not make any friends. He paid no attention to studies nor played any
game, instead he manipulated any toy he was given. He continuously kept fidgeting.
He kept hitting things with leg or keeps moving them. Due to extreme disturbance in
 50

studies and paying attention to anything, he was seeking treatment in insight mind care
center Sahiwal.

Background Information

Personal History

Client mother reported that he was a premature baby and born through C-
section. Client was underweighting and was kept in nursery for 48 hours. His bowel
movements were delayed and he still bed wets. His developmental milestones were
delayed as well. He started walking at age of 4 and speaking at age of 6. His sentence
was although not yet cleared.

Family History

Client belonged to good status of family. Family was consisting of 5 members;

client father was a business man and his mother did a job in bank Client both parents
were alive. Client relationship with his siblings was not good, such as showing irritating
and arrogant behavior and mood.

Pre- Morbid Personality

According to client mother before his illness, Client spent most Time on playing
game although like singing kept watching TV playing some music. Most of the time he
showed pleasant and happiest mood Also take part in daily routine activities.

History of Medical Illness

Client was a premature baby at birth, and his younger brother also a premature
baby according to his mother he had some issue in his childhood and his maternal uncle
also had learning problems. So, this give assurance that there was a sign of medical
illness record.

Psychological Assessment

Psychological assessment was done both at formal and informal level.

 51

Informal Assessment

• History Taking
• Behavioral Observation
• Mental State Examination

Formal Assessment

• ADHD Rating Scale IV Home Version

Informal Assessment

History Taking. History taking for a child involves a structured approach to

gather important information while ensuring the child feels comfortable. It starts with
building rapport with the client and informant, then collecting developmental history,
medical history, and behavioral observations regarding attention span and impulsivity.
Family and social histories are also important to understand any potential influences on
the client behavior (Bickley & Szilagyi, 2017).

Client was interviewed to know about predisposing factors but he did not
cooperate much, just reported lack of interest in studies and inability to focus, the
interview did not last for more than half an hour.

Behavioral Observation. Behavioral observation essential for assessing client

symptoms in real world settings. It involves watching the client in various
environments, such as home and school, to identify patterns of inattention,
hyperactivity, and impulsivity (Smith, 2020).

The client apparently seemed to be 9 years old. His weight and height were not
age appropriate his hygiene was maintained. His speech and comprehension were not
age appropriate. He lacked concentration and fidget continuously.

Mental State Examination. Mental State examination (MSE) in children is a

structured assessment tool used to evaluate various aspects of their psychological
functioning. It includes observing the child’s appearance, behavior, mood, speech,
thought processes, cognition, and insight include attention span, impulsivity, activity
levels, and social interaction (Bickley & Szilagyi, 2017).
 52

Appearance. Client entered with his mother, He was wearing a clean blue dress
and mood was quite strange as if he didn’t want came around. Client often appears very
restless and unsettled exhibit restlessness and disorganization in his movements and
find it difficult to stay in one place. Struggle to maintain focus and tend to shift attention
quickly.

Attitude. Client attitude was different client attitude was not cooperative
Behavior was disorganized and irritable, become easily frustrated and was prone to
worry. When he entered in the room his eyes were not static. he was watching here and
there.

Behavior. Typically show disorganized and impulsive behavior finding. Client

was showing psychomotor agitation He was moving his trunk to and for and sometimes
he began to shake his leg.

Speech. Client exhibits various speech patterns often speak in a disorganized

manner, impulsively, and frequently shift topics during conversations. He could not
speak properly.

Mood. Client mood was mostly irritated. He was having anxious mood
throughout the interview. His mood changes easily, and express different emotions.

Thought Process. Typically, cognitive operations were disorganized, restless,

and easily distracted, leading to forgetfulness and difficulty in maintaining focus on the
conversation.

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

Thoughts was diverse and vary. Exhibit racing thoughts, had difficulty staying on topic,
or show impulsivity in his responses.

Orientation. Orientation of client was fluctuated. Had difficulty maintaining a

consistent focus on time, place, or situation, be altered, leading to difficulties in
maintaining standards of time and place.
 53

Orientation of Place

‫وہ‬
‫آپاہکںآئ ہ‬

‫اشدیاتپسہل‬

‫ہ‬

Memory

Remote Memory

‫ئ‬
‫آپاہکںدیپاوہ ہ‬

‫ہتپںیہن‬

Recent Memory

‫ہ‬
‫آپاسوقاہکں ہ‬

‫آپوخداسوقاہکںوہ‬

Concentration

‫ھ‬
‫اتکبملقدواتوکاسرتیتےسڑپ ہ‬

‫اتکب‬،‫ملق‬

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

General Information/Intelligence. Client had general knowledge about little

things. He had difficulties replied to my all question asked simply from his daily life.

Insight. Insight of client was limited at times. He was s struggling to recognize

the impact of his behavior or the consequences of his actions. Lack of insight
 54

Formal Assessment

The ADHD Rating Scale IV home version (DuPaul et al., 1998). The ADHD
rating scale 4 home version is a widely used assessment tool designed to evaluate
symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) in children and
adolescents. This scale helps in identifying the presence and severity of ADHD
symptoms based on parent or caregiver observations. It includes items that correspond
to the diagnostic criteria for ADHD.

The scale typically covers areas such as inattention, hyperactivity, and

impulsivity, allowing for a comprehensive assessment of the child’s behavior in various
settings. The results can assist healthcare professionals in diagnosing ADHD and
developing appropriate treatment plans.

Table 4.2

Ranges Client Score Level

0-23 Normal
24-39 Mild
40-59 Moderate
60-higher Above 90 Severe

Interpretation. According to the test results above 90% overall the client score
was indicating a severe level of attention deficit hyperactivity. Based on test
administered, the client had problems with attention deficit or hyperactive behavior. He
had all the required symptoms of an attention deficit hyperactivity. These symptoms
were seen in school, family and society.

Diagnosis

According to DSM 5-TR 314.01(F90.2) client was suffering from severe

symptoms of attention deficit hyperactivity disorder (ADHD) because he had
complaints of shaking hands and legs, attention deficit, bullying mutism, study
problems, not getting the task done and difficulties in organization.
 55

Client Prognosis

The prognosis of client was not good because he had not good insight regarding
problem. client behavior was not cooperative. Client attitude was difficult to
understand, and although he did not show any warmth towards his treatment, he did not
give any particular answer to it.

Short- Term Goals

• Psycho education was done with mother and to guide her with the problem of
client
• Rapport building
• Making an environment suitable to change client behavior
• Concrete and clear verbal instructions to help him better understand and
implement
• Praising and reinforcing for positive behavior
• Social skills to help him get along with others

Long- Term Goals

• Setting goals to enhance organizational skills, time management, and study

habits to succeed in school.
• Enhancing social skills: Working on improving communication, conflict
resolution, and cooperation with peers to foster positive relationships.
• Implementing effective coping strategies: Teaching to techniques to handle
stress, frustration, and challenging situations in a constructive manner.
• Reinforcement- to reduce vandalism and risk-taking behavior in client

Treatment

Techniques Applied

• Rapport Building
• Psycho Education
• Role playing Technique
• Reinforcement Technique
 56

• Exercise and Physical Activity

Rapport Building. Rapport building is a technique in therapy that focuses on

creating a trusting and empathetic relationship between the therapist and client. It
involves active listening, genuine interest, and a safe environment, which enhances
communication and therapeutic effectiveness (Rogers, 1961).

Psycho Education. Psychoeducation is a therapeutic approach that educates

individuals about their mental health conditions, enhancing understanding and coping
skills. It helps improve treatment adherence and reduces stigma (Mueser & Gingerich,
2006).

Role Playing. Role playing is an effective technique for helping children

practice social interactions in a safe environment. By simulating real-life scenarios,
children learn appropriate responses and social cues (Mikami & Hinshaw, 2006).

Reinforcement Technique. Reinforcement techniques are strategies that

encourage desired behaviors by providing rewards or positive outcomes. Positive
reinforcement involves giving a reward, like praise when the desired behavior occurs,
which increases the chances of that behavior being repeated. Negative reinforcement,
on the other hand, removes an unpleasant stimulus when the desired behavior is shown,
also promoting its recurrence. (Cooper et al., 2007).

Physical activity scheduling Technique. Physical activity scheduling

technique helps children with ADHD by providing a structured routine for regular
exercise, which can improve focus and behavior. Incorporating activities like sports or
outdoor play allows them to channel their energy positively (Gowan et al., 2016).

Technique Suggested

• Environmental Modifications

Environmental Modification. Adapting the client environment to reduce

distractions and create a conducive setting for managing ADHD symptoms effectively.

Suggestions

• Encouraging self-expression: to share thoughts or feelings about activities.

 57

• Suggest finding activities or hobbies that excite client to boost motivation.

• Encourage setting small, achievable goals each day to build confidence.
• Regular physical activity was advised to help improve focus and mood.

Limitations

• Difficulty concentrating for long periods of time.

• Interrupting a continuation of session
• Different responses to treatment methods.
• Maximum fatigue information
• Strong emotions hinder participation.
• Challenges with organization and planning
• Client short attention span and restlessness make it hard to focus
 58

Session Report

1st Session (35 to 40minutes)

In this basic focus on building rapport and establishing a safe and trusting
environment. Start by conducting an initial assessment to gather information about the
client symptoms, challenges, and strengths. It’s important to involve the client parents
in the discussion to understand client perspective.

2nd Session (40 minutes)

In this session continue building on the rapport establish clients in the initial
session. Delve deeper into the assessment findings, maintain open communication with
the client and his mother to ensure a collaborative approach, provide psycho education
about problem and Treatment. Discuss about test which was applied in next session.

3rd Session (65minutes)

In this session test were administered. Before administering the test, Fill
informed consent. Start by gathering all necessary materials including the Conner’s
parents Rating Scale questionnaires for informants, and the client Schedule a session in
a comfortable and quiet setting to minimize distractions. Explain the purpose of the test
and informants ensuring they understand that it meant to help identify behaviors and
support needs. Establish rapport with the clients to make feel at ease ADHD Rating
Scale applied by first ensuring a calm environment for client and provide the relevant
questionnaires to informants, and the child themselves. After complete the forms,
collect and score according to the guidelines. Finally interpret the results, looking for
patterns in behavior.

4th Session (50 minutes)

After looking at the test result, start by explaining what the scores mean.
Compare the client scores to what typical for client age to help understand where he
stands Then, talk with the client and informants about what these results mean for child
, Work together to come up with a plan that include technique for behavior, or support
at school.
 59

In this session too, work on techniques start applied specific technique including
Role playing technique and reinforcement technique tailored to the client need.

5th Session (55 minutes)

Continue to assess the client progress. continue assessing the client

development, addressing any new obstacles, and adjusting the treatment plan as needed
the process of different techniques of client improvement continued this technique
Involve. Role playing technique and Physical activity scheduling technique was and
practice.

6th Session (50 minutes)

In which some techniques were suggested include environmental modification

setting specific goals for the client to work on, like improving focus or reducing
impulsive behavior. Introduce visual aids, like charts or checklists, to help the child
stay organized and on track. Role-playing social situations help improve child
interactions with others. Talk about next steps for continuing progress at home and
involve parents in the discussion. Encourage the child to ask questions and wrap up
positively by highlighting his strengths and achievements, ensuring he feel supported
moving forward to managing client problem
 60

Case Summary

Client name was HA, 5-year-old boy. Informant contacted due to the presenting
complaints include exhibit challenges in social interaction, communication difficulties,
repetitive behaviors, restricted interests, sensory sensitivities, and resistance to change.
6 sessions were conducted. According to DSM 5-TR client diagnosed with autism
spectrum disorder 299.00(F84.0)

Client was assessed using informal as well as formal assessment including

history taking, behavioral observation and Mental State examination of presenting
complaints while for formal assessment social communication questionnaire (SCQ)
was administered.

Role playing technique, picture exchange communication system applied as

management plan and applied behavior analysis (positive reinforcement technique) was
suggested. The sessions process helped much in improving autism spectrum disorder
(ASD) problem of client.
 61

Introduction of Disorder

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition

that affects communication, behavior, and social interaction. It is characterized by a
wide range of symptoms and levels of impairment, which is why it is referred to as a
“spectrum.” Individuals with ASD may exhibit difficulties in understanding social cues,
forming relationships, and engaging in typical communication patterns. Additionally,
they may display repetitive behaviors or restricted interests. The exact cause of ASD
remains unclear, but research suggests that genetic and environmental factors play a
role in its development (Wood, 2013).
 62

Identifying Information

Name HA

Age 5 years

Gender Male

Father Farmer

Mother House wife

Number of Sibling 03

Birth order 2nd

Referral source Mother

Session 06

Reason for Referral

The client was referred by the psychiatrist to trainee clinical psychologist for
the purpose of k2psychological assessment and management.
 63

Presenting Complaints

Table 5.1

‫ین‬
‫دورا ہ‬ ‫العامہت‬

‫شئ‬
‫دیپا ہ‬ ‫کشم‬
‫ںیم ہ‬
‫امسیجلیموجل ہ‬

‫شئ‬
‫دیپا ہ‬ ‫کشم‬
‫ےنںیم ہ‬
‫ابتتیچرک ہ‬

‫شئ‬
‫دیپا ہ‬ ‫یپسچل‬
‫یسکیھباکمںیمتہبمکد ہ‬

‫شئ‬
‫دیپا ہ‬ ‫یسحاسحتیس‬

‫شئ‬
‫دیپا ہ‬ ‫ابر‬need.‫اکمرکانہ‬
‫ہ‬

Initial Observation

Client was 5 years old boy with causal appearance. The client appearance was
characterized by limited eye contact, unique behaviors, and focus on specific objects.
Client had unusual body language, reflecting his individual sensory preferences and
level of social engagement. Difficulty initiating conversations and answering questions.
Prefers solitary play and shows little interest in playing with peers. Shows repetitive
behavior.

History of Present Illness

According to the mother, when the client was born, his condition was very bad.
For this, he was admitted to the hospital for a long time under full supervision. After a
few days when his condition Improved, he was discharged, but even then, his condition
was never very good, but the condition of the child was quiet as he grew up. His
condition was the same, there was no significant difference‫۔‬In the beginning, we
thought that he might be change, but time will pass and his condition will be the same ,
meaning his actions and signs were something like Signs of limited eye contact, Lack
of response to own name, Delayed speech was too little to smile, Repeated hand
 64

flapping, Sensitivity to sensory input. But in the beginning, we did not pay any special
attention to this problem. But now we started to worry that it was not all right for his
age, there must be some problem‫۔‬

Background Information

Personal History

Client mother reported that he was born through operation. Client condition was
very severe by birth so he was kept in nursery for few days, when condition improve,
he was discharge. Crawled at 11 months walk at 15 months. limited interactions with
peers.

Family History

Client belongs to Average status of family. Family was consisting of 6 members;

client father was a Farmer and his mother was also teacher. Client both parents were
alive. client grandfather had died while the grandmother was alive and she lived with
them. The client had two siblings, an older brother and a younger sister. Client
relationship with siblings was not stable, such as showing irritating and arrogant
behavior.

Educational History

The client had not yet started school. Go to a public school that does not have
special education resources He had attended for a few days but had not yet been sent
back to school Because of struggles with basic letter and name skills.

Past Medical & Psychiatrist History

According to client mother, client condition faced many complications from the
time when he was born. And since then, it had been the same. And they said that this
problem only with him. The rest of client sibling was completely normal.
 65

Pre-Morbid Personality

According to the mother when he was born, his condition was very bad, due to
which he was also admitted to the hospital, after which his growth and development
was very slow compared to other children.

Assessment

Informal Assessment

• History Taking
• Behavioral Observation
• Mental State Examination

Formal Assessment

• Social communication Questionnaire (SCQ)

Informal Assessment

History Taking. History taking is a vital process that involves collecting

detailed information about a person health, including the client complaint, present
illness, past medical history, medications, allergies, family and social history, and a
review of systems (Bickley, 1991).

Behavioral Observation. Behavioral observation for children with focuses on

assessing their social interactions, communication, and repetitive behaviors to identify
strengths and challenges (Wood, 2006).

Mental State Examination. Mental State examination (MSE) is a structured

way of observing and describing an individual psychological functioning at a given
point in time. It covers various domains, including appearance, behavior, mood, thought
processes, cognition, and insight. (Bickley & Szilagyi, 2017).

Appearance. The client showed irritability, avoiding eye contact, focusing on

specific objects, and repetitive movements.

Mood. The mood of client varies feel anxious, excited, or curious.

 66

Attitude. The attitude of client appeared withdrawn or resistant.

Behavior. Client showed repetitive behaviors or experience meltdowns. This

depends on client comfort zone.

Orientation. Orientation refers to understanding one’s position and direction in

relation to the surrounding environment. It includes recognition of time and place (kail,
2016).

Orientation of Person

‫آپسکےکاسھتآےئہ‬

‫ایم‬

Orientation of Time

‫ہیوکاسنوتقہ‬

‫ںیہناتبای‬

Memory

Recent Memory

‫آپاہکںوہ‬

‫اتپسہل‬

Recent Past Memory

‫آپےنلکایکاھکایاھت‬

‫اخومش‬
 67

Intelligence‫ہ‬

‫اکیعمجاکیےنتکوہےت‬

‫دو‬

Thought Process Client thought literally and struggle to understand abstract

concepts. Client focused tends to on specific interests or routines.

Thought Content. Client focused on specific topics or interests. Client thought

content was repetitive or obsessive, affecting daily life.

Perception. There were no signs of hallucinations and delusions. Client

interpreted sensory stimulus according to his interest and repetitive behavior.

Insight. Client had no insight about his problem.

Formal Assessment

The Social Communication Questionnaire (Rutter et al., 2003). The Social

Communication Questionnaire (SCQ) is a screening tool used to assess social
communication and behavioral issues related to autism spectrum disorder (ASD). It
consists of 40 questions answered by parents or caregivers, focusing on the child’s
social skills, communication abilities, and repetitive behaviors. The SCQ helps
determine if further evaluation for ASD is needed. It is important to note that the SCQ
is a screening tool, not a diagnostic instrument.

Table 5.2

Ranges Client Score Level

0-15 Mild
16-25 19 Moderate
26-40 Severe

Interpretation. Client obtained score 19on social communication questionnaire

(SCQ) which led to moderate level of autism spectrum disorder (ASD). Based on
administered test Client symptoms on the Social’ Communication Questionnaire (SCQ)
 68

include difficulties in social interactions, lack of interest in conversing with others

challenge in making friends trouble understanding social cues, and a preference for
routines. He had all the required symptoms for autism spectrum disorder (ASD). These
impairments had been shown in school, family and society.

Diagnosis

According to DSM 5-TR client diagnosed with autism spectrum disorder

299.00(F84.0)

Client Prognosis

The prognosis of client was not good because he had no insight regarding his
problem.

Intervention Plan

Short Term Goals

• Establish Rapport building

• Provide Psycho education about client problem
• Making environment comfortable

Long Term Goals

• Implementation of short-term goal

• Follow up session would conduct
• Focus on increasing communication and social engagement.

Treatment

Technique Applied

• Rapport Building
• Psycho Education
• Picture Exchange communication style
• Role Playing Technique
 69

Rapport Building. Rapport building is a technique in therapy that focuses on

creating a trusting and empathetic relationship between the therapist and client. It
involves active listening, genuine interest, and a safe environment, which enhances
communication and therapeutic effectiveness (Rogers, 1961).

Psycho Education. Psychoeducation is a therapeutic approach that educates

individuals about their mental health conditions, enhancing understanding and coping
skills. It helps improve treatment adherence and reduces stigma (Mueser & Gingerich,
2006).

Picture Exchange Communication System. This is a visual communication

method designed for children who struggle with verbal communication, such as those
with autism spectrum disorder (ASD). In this system, children use pictures to express
their needs and desires, which helps improve their communication skills (Bondy &
Frost, 2001)

Role playing Technique. Engage the client in role-playing scenarios to practice

social skills in a controlled environment, allowing them to practice social interactions
and responses in simulated scenarios (Henggeler et al., 2009).

Technique Suggested Applied Behavior Analysis

Applied Behavior Analysis. is a scientific approach used to understand and

change behavior, primarily through positive reinforcement. It is commonly used for
modifying behaviors in children with autism spectrum disorders (Wolf & Risley, 1968).

Suggestions

• Use social stories to help client understand social situations.

• Engage client in interactive play activities like role-playing or board games.
• Incorporate sensory activities, such as clay or water play, for relaxation and
focus.
• Establish daily routines for predictability and security.
• Encourage to pursue hobbies based on client interests, such as art or drawing
• Provide consistent feedback to help them see improvements in client behavior
and skills.
 70

Limitations

• Communication barriers prevent client from expressing feelings or needs.

Social interaction challenges make hesitant to engage with therapist
• Disruption of established routines lead to behavioral changes.
• Limited interest in clinical activities reduce participation.
• Focus and attention issues hinder achievin
 71

Session Report

1st Session (50 minutes)

In this basic focus on building rapport and establishing a safe and trusting
environment. Start by conducting an initial assessment to gather information about the
client symptoms, challenges, and strengths.

2nd Session (40 minutes)

Continues to build rapport and trust Further explore the client symptoms,
triggers, and challenges was client facing. To create a safe and supportive environment
for client to express his feelings and concern, provide psycho education about client
problem and issue. Start by checking in on how client had been feeling since the last
meeting. Discuss the informant about the test was applied in the next appointment.

3rd Session (45 minutes)

In This session test were administered. Before administering the test, Fill
informed consent. Start by gathering all necessary materials including the social
communication questionnaire (SCQ) and Schedule a session in a comfortable and quiet
setting to minimize distractions. Explain the purpose of test. Establish rapport to make
feel at ease. social communication questionnaire (SCQ). After complete the
Questionnaire collect score according to the guidelines. Finally interpret the results, and
discuss with client mother.

4th Session (40 minutes)

Review about previous session any concerns and challenge relate to test and
overall session. Explain the findings in relation to the client symptoms and mental
health. In this session basic focus on introducing specific therapeutic techniques or
strategies based on the assessment outcomes, aiming to enhance the client self-
communication and engagement in the treatment process. This technique included
picture exchange communication system (PECS) and ask parents to practice this
technique at home with client
 72

5th Session (35 minutes)

Continue to support his delving deeper into his emotions, adjusting the plan,
sharing more about client problem, and strengthening the bond. Continue of applied
technique earlier and introduce role playing technique.

6th Session (40 minutes)

In this session basic focus on previous applied technique and some techniques
were suggested Applied Behavior Analysis (positive reinforcement technique) to
encourage desired behavior. Talk about next steps for continuing his progress at home
and involve parents in the discussion. Encourage to ask questions and wrap up
positively by highlighting client strengths and achievements, ensuring client feel
supported moving forward to managing problem
 73

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