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Case REPORT- 2
Bio data
Name: T.y
Age: 52years
Gender: Female
Religion Islam
No of siblings: 5
Birth Order: 2
Status: Married
No of children: 2
Qualification: FA
Occupation Teacher
Identify information
52 years old a female. Her education is FA. She is married She belong to middle standard family.
She has two daughters. Her husband is bank manager and she is a teacher in government girls
high school.
Reason for Referral:
The client come itself because she feels she disturb in her life. Many problems and issues disturb
her daily life activity. People said him what is problem in her life why she changes and silent.
Presenting complaints
Aggressiveness, hopelessness, Muscle tens, Weeping episode, Palpitation, Irritability, Low
mood, Fatigue, Helplessness and Isolated.
Interviewer information
According to client she is in sever tension. her childhood spends very well and adulthood is also
well. But she faces many problems after marriage after one and half year completed when her
husband became paralysis completely on bed. She mange this trauma of her life. She is the EST
teacher in government school. She said that she has two daughters and no son. she works hard to
give her daughters best life. She helps him in every field of life she gives proper education. She
done very hard duty in her whole life. She said that now she feels tired she look after 25 years of
her husband and also other family members now her husband was died four months is completed
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of his death after death of her husband she feel alone she said that she has no meaning of her life.
People is selfish near him she cannot trust anyone in his life. She also said that she feels
importance of a son in her life. Now a day she become more aggressive. She feels she has no
purpose and meaning in her life. She like to sit separate cannot talk and busy in her thinking. She
also said that no one can help Allah always help a person.
In past history she said that her husband already got married he have one son and one daughter of
his first wife. He could not live with him because his first wife is not educated and his behave is
not good with her husband. She is cousin of her husband. Client said that my husband was very
caring loving and supportive with me in one and half year and then his condition is critical. She
faces many problems during this period.no one help me but I manage this phase very well.
Behavior during testing session
The client Behavior during testing session is not supportive. Therapist faces many problem and
related difficulties during testing session. Main problem he faces during TAT client refuse to tell
the story when he done nine card she again creates problem in blank card. But when therapist
encourage in positive way then she response very well.
Testing administered
 Standard Progressive Matrices (SPM)
 Human figure Drawing (HFD)
 Thematic Apperception Test (TAT)
 Rotter incomplete sentences blank (RISB)
Psychological Evaluation
Standard Progressive Matrices(SPM) a test of abstract reasoning (it is one aspect of intelligence)
which indicate that subject intellectual capacities fall grade third which indicate intellectually
average.
Human Figure Drawing Test (HFD) a projective test, indicates that the client draws human
figure which shows that she feels helplessness. Her human figure shows that immaturity her
drawing ty in drawing her drawing shows that poor integration about body parts.
In addition, a projective test Thematic Apperception Test (TAT) indicate that client has need of
love achievement and affiliation. She uses different defense mechanism like repression denial
and rejection relationship. Her stories show that she many issues in her life.
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In personality test Rotter incomplete sentences blank(RISB) indicate that subjective have
maladjusted personality. she faces many adjustment issues during the period of migration. her
RISB obtaining score is 164 it is above of cutoff score cut off score is 135. which indicate she
has maladjustment issues. more conflicts in her life she cannot adjusts easily but mange with
this issue.
Tentative diagnosis
300.4 (F34.1) Dysthymia
Prognosis
The prognosis of the client was satisfactory. And the client has more insight about her problem
and is motivated to treat her problem. She did response to psychological treatment and
psychotherapy.
Recommendation
CBT Cognitive behavior therapy is best treatment for this client.
Psycho education
Conclusion
Client is 52 years old female from Faisalabad. Assessment is done by using different
psychological instrument Clinical interview, Mental state Examination (MSE), Rotter’s
Incomplete Sentence Blank Test (RISB), Standard Progressive Matrices (SPM), thematic
apperception test (TAT) and Human Figure Drawing (HFD).in RISB test her obtaining score
indicate that she has adjustment issues. SPM indicate she has intellectual average. TAT
projective test indicate that she uses many defense mechanisms., conflict needs and press in her
life HFD result show her helplessness and other issues.
On the basis of her symptoms 5 years is completed of his problems dysthymia was diagnosed.
For the purpose of treatment different techniques were used such as Cognitive behavior therapy,
and psycho education etc.

Limitation
Through all process many problems and difficulties face main problem is timing issues. And
during testing session client create many problems. She cannot take interest and show irritability
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specially during TAT administration phase. In the last blank card, she refuses to tell me story.
But when I motivate him she response good.
Supervisor Examiner

Treatment plan
Case Number 4

Gender Female

Symptoms Aggressiveness, hopelessness, Muscle tens, Weeping

episode, Palpitation, Irritability, Low mood, Fatigue,
Helplessness, excessive thought and Isolated
Diagnosis
(principle) 300.4 (F34.1) Dysthymia

Target
Symptoms Aggression, negative thinking, muscle tens, low mood and
fatigue.

Treatment Goals  Rapport building and confidentiality.

For  Work on improving aggression.

Target  Educate the client how control their emotions.

 Find main reason which cause increasing depression.
symptoms
 Change negative thinking into positive thinking.
Treatment
Approach Cognitive behavior therapy CBT
Initial Phase History taking
Rapport building
Middle Phase In Counseling session CBT is used morning evening walk deep
breathing Socratic dialog and muscle relaxation therapy is
recommended for best treatment.
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Termination Give Fallow up plan and asked the client check after three

Phase months and report related her problems. Client should follow this
plan two year.

Number of 12to 20 session is necessary for best treatment.

sessions
Required to
achieve goals
(Approximately)

Supervisor Examiner