GENERAL DATA:

Client is a 37-year old male confined at DOH Treatment and Rehabilitation Center,
Tagaytay City on August 4, 2017. The client was born on August 25, 1980 and raised at Bacolod
City but later on migrated to Caloocan City. He’s the second child of Mr.Randy and Mrs. Edith
Silos. The client was confined inside the Rehabilitation Center due to court’s order of being
rehabilitated for 12 months. He was referred for a psychological evaluation to determine his
current cognitive and emotional status.

SOURCES OF INFORMATION:
Background information were from intake interview session of Client. and some
additional information were gathered from his dorm strength and elder. There were
standardized psychological tests conducted to the client to determine and comprehend his
current cognitive and emotional status. Also, there were behavioral observations noted in
constructing the report.

BACKGROUND HISTORY:
Client. or also known as “Toto” is a 37-year-old unmarried man born at Bacolod City and
later on migrated to Caloocan City. Toto was confined inside the DOH Treatment and
Rehabilitation Center for almost 6 months. He’s the middle child among three children of Mr.
Randy and Mrs. Edith Silos.
During birth, the client was delivered as “suhi”. His parents were the ones who raised
him so he developed close relationship towards his mother. According to the client, he cannot
recall some events of his life especially during his toddler’s stage. However, he remembered the
story of his mother when he was 5 years old when his sister accidentally gave him a gasoline
drink. He was rushed to the hospital and was confined for almost a couple of days. He
developed few acquaintances during his childhood stage because he excluded his self to people
who belittled and criticized him. He chose to play with his cousins and siblings. Most of the
time, he spent leisure time inside their house watching television and playing indoor games
with his siblings.
While growing up, he was exposed to an environment where he witnessed physical and
verbal aggression within his extended family. Due to this, the client realized that, “Walang
ibang tao ang dapat manakit sa akin o maliitin ako. Saka kapag kapamilya ko ang nasaktan,
kahit sino pa ‘yan, papatulan ko.”
 The client started schooling at the age of 5 in Bata Elementary School. According to the
client, he was a stubborn student but cheerful at the same time. There were times that he was
fond of giving flowers or token to his teacher. During sixth grade, the client excelled in his
academe wherein he received awards like Best in Math and Best in Writing. Also, the client was
given an opportunity to join Boy Scouts of the Philippines. They went to Masbate to join in
camping for almost 3 months. He finished his sixth grade with honors. Nonetheless, when Toto
reached first year highschool, he started to violate the rules and regulations of the school. The
client was caught smoking inside the vicinity and was involved in cutting classes. Moreover,
there were times that the client stole money from his father just to brag.
At the age of 12, he boarded a ship out of curiosity and reached Luzon. Unfortunately,
he was caught by the captain. According to the client, he was sent to the captain’s relatives
where he worked as a helper in the market. During his first stay, he was asked about the
information of his parents but he only gave their telephone number. So, his boss called his
family and informed that Toto was in safe hands. Toto and his boss had a good relationship that
lasted for two years. When he was 15 years old, he went back to his birthplace to continue his
studies.
In the same year, he continued his 2 nd year highschool. He developed group of friends
whom he referred as bad influence. He started drinking alcohol and smoking cigarettes. He was
not able to finish his third year level due to desperate substance use. Moreover, the client
stated being easily annoyed which resulted to his involvement to numerous gang fights. At a
young age, he was detained in jail for three times. When he was 17, Toto and his family decided
to migrate to Caloocan City where he had jobs like construction worker, dispatcher, electrician
and painter. He became regularized as a tinsmith and had a monthly income. At this stage, he
was exposed to an environment where drugs were pervasive. He preferred to be with his
company rather than staying at home. He started using stimulant with small amounts. By this
time, his family started suspecting about his substance use due to increasing times that he
came home high on drugs. According to Toto, he can’t forget the time when he shouted and
bad mouthed his sister and nephews without any reasons that eventually led to their present
emotional conflict.
He used cannabis only for a couple of months because he disliked its effects such as
craving for the substance. However, his stimulant use increased in quantity. He would buy
stimulants with his monthly income in order to satisfy his daily cravings. Later, he stopped
working and decided to sell methamphetamine or “shabu”. According to the client, he
preferred to sell shabu in order to have a weekly income and a continuous supply for his
personal use.
When the client was 20 years old, a drug raid occurred in Caloocan City and he was
caught in the act of using illegal drugs. Consequently, he was detained in Manila City Jail for
about a year. Year 2002, he got involved in a physical fight where he was stabbed thrice. Due to
this, he was hospitalized for a month. At the age of 23, he was sent to jail with the same issue
of substance use. While inside the jail, he again encountered the person who stabbed him and
was a fellow inmate that time. Out of his desire to get even, he ordered his friend to murder
that person. When he aged 25, he was again confined for 7 months in Caloocan City Jail
because he was again arrested during a drug raid. Moreover, he started selling drugs to his
fellow inmates while he was inside the jail.
At the age of 28, the client met his live-in partner named Shiela. He stopped using shabu
for a week when he visited the family of Shiela at Isabela Province. When he returned to
Caloocan City, he continued his substance use. They were together for almost two years and
got separated because his partner had an affair with another man. When he was 30 years old,
he had his second girlfriend named Rowena. Their relationship only lasted for months because
his girlfriend caught him using drugs inside their comfort room. Later, he met his third girlfriend
who immediately found out about his substance use and broke up with him.
Year 2010, the father of the client died due to lung cancer. He claimed to be depressed
for a week and the amount of his substance use increased. Moreover, the client stole the
supposed funeral donation of his father and spent it for his own satisfaction.
In April 2, 2017, he was imprisoned for 4 months due to abusive used of drugs and on
August 4, 2017, he was sent to DOH – Treatment and Rehabilitation Center in accordance with
a court order.
During the interview, the client claimed that he was the black sheep of their family. He
wanted to ask forgiveness from his mother and his sister. Also, he added that he felt guilty
everytime he remembered the murder of his fellow inmate by his orders. According to the
client, there were times when he was found alone in a corner as he was preoccupied of his
problems. When he was admitted inside the Rehabilitation Center, he reported pain in his arms,
dizziness and blurred eyesight. He also added that he miss selling drugs inside and outside the
jail.
According to his dorm strength, the client got involved lately in a fight where he
punched his brother’s face due to anger. When it comes to his performance inside the dorm, he
followed and obeyed rules, however he easily gets annoyed with other people who belittle and
make fun of him. According to his elder, Toto was a follower and a kind person inside the
Rehab. In addition, the client followed rules and respect his superior. Also, he stated that the
incident happened because Toto got driven by his rage towards his brother who disparaged
him. There were times that the client was found crying and isolated inside the Rehabilitation
Center.
The client stated that he cannot make a promise of not returning to his old life once he
finished the program inside the Rehabilitation Center. However, he stated that he would make
sure to choose his group of friends properly and be a Born Again Christian affiliate.
HEALTH AND MEDICAL OBSERVATIONS:
The client and his friend got involved in a motorcycle accident which left him scars on
his face. Year 2004, the client was confined at the hospital for almost a month because he got
stabbed with a knife on his body.
During his conception, the mother of the client received enough nutrients to sustain his
child. However, there were times when his mother got dizzy and tired because of too much
work. The client completed 9 months and was delivered as “suhi”. At the age of 5, he was
accidentally given gasoline as a drink by his sister. He was rushed to the hospital and was
confined for a couple of days.
His father died due to lung cancer while the client’s mother developed complications to
her eyes and her joints weakens. As per the account of the client, when he was confined inside
the Treatment and Rehabilitation Center, he developed unexplainable pain on his arms, blurred
vision, and at times he felt dizzy.

PHSYICAL AND BEHAVIORAL OBSERVATION:

The client stands about 5’4” and weighs about 58 kg. He has a fair complexion, a tattoo
on his arms, fingers and at the back of his body. Scars on his face were observable. As the client
entered the room with gait walk, he approached every personnel with excitement as he grinned
and waved his hands. During the test administration, he was sitting on his chair wearing the
prescribe ward uniform paired with slippers. The client has a mesomorphic body built. He
appeared to have good grooming but poor hygiene because most of his teeth were decayed. He
can maintain eye contact. The client was talkative and he responded to the interviewer with a
loud voice. There were times that his speech rate was rapid and has normal intelligibility. He
was not hesitant to answer the questions as he spontaneously responded to the interviewer.
The client was responsive and cooperative.
He appeared to have euthymic mood and appropriate affect. There were no presence of
perceptual disturbances such as hallucinations or delusions. Also, there was no evidence of
disturbances in the form of thought. The client was oriented to time, place and person but had
two trials in recalling the words “Mangga, Mesa, Pera”. Also, he developed difficulty in
repeating the words “Datapwat, subalit at bagamat.” It was notable that the client has remote
memory deficit as indicated by his responses. Moreover, the client got easily distracted by his
environment. The client has good judgment but has inconsistent answers to the interviewer. He
has consistent answers when it comes to his age of first use of different substances, names of
his past romantic relationships and years of his detainment.
When he took the House-Tree-Person Test, he drew a tree and below it, he drew five
persons namely Ana Marie, Rachel, Robert, his brother and the client. During the HTP
interrogation, he told the interviewer that these people were his friends during his childhood
stage. However, contradict to his clinical interview, he had no friends like Ana Marie, Rachel
and Robert.
During test administration and interview, he was preoccupied by his family. The client
has no reported suicidal ideation but there were reported history of violence.
TEST ADMINISTERED:
House-Tree-Person Test
The Forer Structured Sentence Completion Test – FORM MAN
Hospital Anxiety and Depression Scale in Filipino Version (HADS-P)
Bender Gestalt Visual and Motor Test-II
Kauffman Brief Intelligence Test
Minnesota Multiphasic Personality Inventory-II (Invalid)

OTHER EXAMINATION
Mini-mental Status Examination
Clinical Interview

TEST RESULTS:
The client’s current cognitive and emotional status were the focus of this evaluation. On
his current cognitive status, the test revealed that the client’s Nonverbal IQ composite falls on
lower extreme level. He may have poor performance when it comes to complex situations, such
as abstract reasoning, decision making, and solving problems. Also, he might encounter
difficulty when it comes to written materials. Similarly, his large amount of stimulant use could
explain the mental deficiency showed in the test results.
Results also revealed that client was overly concerned with social accessibility. The client
was emotionally aloof because he excluded his self from people who criticized him. In addition,
he told the interviewer that Ana Marie, Rachel, Robert were his friends during his childhood.
However, based in his clinical interview, he had no friends like Ana Marie, Rachel and Robert.
As compensation, during adolescence, the client surrounded his self with groups who accepted
him.
So, he was concerned about the opinions of others and got easily influence by his peers.
As a result, he took stimulants and joint illegal activities for him to be included.
Aggression and hostility were also depicted in test results. These can be supported by
his past activities where he was involved in numerous gang fights, ordered his friend to murder
the person who stabbed him and lately he was involved in a fight inside the Rehabilitation
Center. Likewise, those aggressive behaviors and social dominance were compensatory
defences due to his inadequate ego control.
 Moreover, it was shown that the client has close regards towards his mother. The client
feels sad when he thinks of his mother. This can be supported by the information that even he
was confined in jail several times, his mother’s unending provisions were given to the client. In
addition, the client has positive relationship to his father and wishes that his father was still
alive. He stated that he felt depressed when his father died. Furthermore, the client has
negative regards towards female and stated that women are “baliw”. As evident to his first live-
in partner when they got separated because of another affair and most of his romantic
relationships failed. Ambivalent feelings were shown towards male, authority, and groups. Also,
the test revealed that the client has possible aggression towards other people who criticize him.
Additionally, the client has wishes to be rich and intelligent for him to be happy. However, he
depicted that he fails to reach his ideal-self due to laziness and abusing illegal drugs. As an
outcome, he blames his self because of his wrong doings.
It was also shown in test results that client has lack of personal warmth in home. As
evident when he boarded a ship and reached Luzon at the age of 12. He remained there for 2
years with different family. Moreover, when they migrated to Caloocan City, he seldom stayed
at home and preferred to hang out with his friends. Due to lack of protection of his mother, the
client engaged to several romantic relationships. He had live-in partners but most of it ended
up to termination. This might be the reason why the client often cannot maintain good
relationship with his past lovers. As a result, client often escape from his feelings of anxiety, and
involved himself into illegal drugs.
In addition, the tests revealed that the client is anxious and depressed. This might be
rooted from his past negative experiences. As middle child, he felt inadequate care from his
parents, he was not able to finish his studies, he had several failed relationships, he was
repeatedly confined in jail and his father died. These events possibly increase the instability of
his emotions which triggered his emotions, resulting for him to have an emotional breakdown.
Hence, the client often cannot handle his unstable emotion, and involved himself into illegal
drugs as his way of escaping from his feelings of frustration.

DIAGNOSTIC IMPRESSION:
Based on the findings, the client is believed to be subjected to psychological condition,
Severe Stimulant Use Disorder, Methamphetamine type, in early remission, in a controlled
environment and Antisocial Personality Disorder with the following manifestations:
Severe Stimulant Use Disorder, Methamphetamine type, in early remission, in a controlled
environment:
1. The stimulant is often taken in larger amounts or over a longer period than was intended.
(The client has been using stimulant since he was 17 years old and uses it daily.
According to the client, his last intake was April 1, 2017.)
2. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use.
(The client tried to stop using stimulants for a week because they visited the family of his
girlfriend at Isabela. Also, he lessen the use of stimulant when he was imprisoned but lately he
continued using and selling drugs inside the jail.)
3. A great deal of time is spent in activities necessary to obtain the stimulant, use the
stimulant, or recover from its effects.
(The client started earning income when he was 17 years old and most of his income
was spent to obtain the stimulant.)
4. Craving, or a strong desire or urge to use the stimulant.
(The client has been using stimulant since he was 17 years old and uses it daily.)
5. Recurrent stimulant use resulting in a failure to fulfil major role obligations at work, school,
or home.
(He stopped attending school, refused his obligations at home and failed to continue his
work just to anticipate using the stimulant.)
6. Continued stimulant use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the stimulant.
(The client continued using stimulant resulting to a termination of his relationship with
his past girlfriends and his relationship towards his sister.)
7. Important social, occupational, or recreational activities are given up or reduced because of
stimulant use.
(His boding with his family were given up and he refused going to his work just to use
and sell illegal drugs.)
8. Stimulant use is continued despite knowledge of having a persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated by the stimulant.
(Despite his reported disturbances in sleeping, he continuously took stimulant.)
10. Tolerance, as defined by, a need for markedly increased amounts of the stimulant to
achieve intoxication or desired effect.
(As the client grows older, his stimulant intake increased.)
Antisocial Personality Disorder
There is evidence of conduct disorder with onset before age 15 years.
1. Failure to conform to social norms with respect to lawful behaviors, as indicated by
repeatedly performing acts that are grounds for arrest.
(At the age of 15, he was imprisoned in jail thrice because of numerous gang fight.
Starting at the age of 20, he was repeatedly confined in prison because of using illegal drugs.
Also, he ordered his friend to murder the person who stabbed him.)
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal
profit or pleasure.
(The client stole the supposed funeral donation of his father and spent it for his own
satisfaction.)
3. Impulsivity or failure to plan ahead.
(The client boarded a ship when he was 12 years old and went to Manila without his
family. Also, he repeatedly used stimulant without forethought.)
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
(He gets easily annoyed by people who criticize him and as a result of involvement to
different fight.)
5. Reckless disregard for safety of self or others.
(The client boarded a ship when he was 12 years old and went to Manila without his
family. Also, he repeatedly used stimulant despite of his parents’ advices and warnings.)
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
(The client stole the supposed funeral donation of his father and spent it for his own
satisfaction. Also, he ordered his friend to murder the person who stabbed him.)

RECOMMENDATION:
The client’s Antisocial Personality Disorder needs further clinical assessment. However,
in order to help the client’s need, the following are several areas that needs to be directed:
1. The client is recommended to continue his counselling sessions to help him reduce
anxiety and depression. Also, Cognitive and Behavioral Therapy could be applicable for the
client to be directed to change his beliefs regarding his maladaptive pattern of illicit substance
and to eradicate his feelings of inadequacy.
 2. The client is recommended to undergo family therapy for him to resolve his issues
towards his mother and sister.
3. The client is recommended to have companion inside the Rehabilitation Center where
he could share his thoughts and ideas.
4. The client is recommended to have daily journal to put all his insights to monitor his
improvements.
5. The client is recommended to be engage to different activities like group dynamics
and focused group discussion inside the Rehabilitation Center that would be beneficial to him
and improves oneself.

JAY-AR D. BAYBAY
Psychometrician

DE LA SALLE UNIVERSITY-DASMARINAS
College of Education Graduate Studies Department
GRSE 200. FOUNDATION OF GUIDANCE & COUNSELING

Name: Jay-ar D. Baybay