Case Summary

The Client A.J was a 27 years old male working in a private company and was referred to

the trainee clinical psychologist with presenting complaints of irritability, aggressiveness, low

self- esteem, sweating, trembling, restlessness, headache, excessive worried about his symptoms.

Formal assessment was done with the help of drug abuse screening test (DAST) and HTP,

informal assessment was done such as clinical interview, behavioral observation, and mental

status examination. The assessment results revealed that the client had symptoms complaints

were due to heroine withdrawal. The management plan was done according to his symptoms

complaints with the help of stages of change model to fallow the different techniques like high

risk/ low risk situation, coping strategies regarding his cannabis addiction, thought record form,

sleep restriction worksheet, progressive muscles technique, (PMR), Deep Breathing, and other

relaxation exercises, and specially work on relapse prevention, while client understand to his

symptoms and mentally prepared to cope this kind of triggering thought that mostly relate to use

cannabis.

Bio Data

Name: A.J

Age: 27

Gender: Male

Marital Status: Married

Education: B.S complete

No. of Siblings: 6
Birth Order: First born

Informant: Client himself

Reason of Referral

Client was referred to Hero health Rehabilitation center by his father for the purpose of

getting rid from drug addiction. He himself wanted to get rid of this addiction as well as his

family was very supportive he is very dear to his family and he felt that recovery is needed to

live a normal and happy life.

Presenting Complaints

A.J was currently in the phase of withdrawal which means he was in the recovery phase

with stable mental state. The client stated the following complaints which he reported and was

feeling from past 3 years;

 ‫دل گھبراتا تھا‬

‫بے چینی ہوتی تھی‬

‫گھبراہٹ محسوس ہوتی تھی‬

 ‫طبیعت خراب ہوتی تھی‬

 ‫چڑچڑا پن محسوس ہوتا تھا‬

Background History

General Home Atmosphere;

A.J belongs to a middle class family, he reported his home atmosphere was usually

friendly, he always had a good relationship with his parents and siblings and he wants to give the

same atmosphere to his son. The authority figure in his home is his father.
Personal History;

Currently the client is in withdrawal state. He was born through normal delivery, he had

no physical illness at the time of his birth and he had achieved his developmental milestones at

an adequate age level. He started taking drugs 3 years ago when he was 24 years old, he first

started taking cigarettes with his friends and then he and his friends switched to heroine due to

that he started showing unstable mental conditions which disturbed his personal life with parents,

siblings and wife. The client had never taken any counselling sessions and had never been

engaged into therapeutic sessions except the one he is taking currently.

Family History;

The client currently lives with his parents, siblings, wife and son. As per client he has a

good and healthy relationship with his family he reported that he was very close to his parents in

childhood, his parents are very friendly and was mostly close to his mother. While in recovery

process he misses his son the most. He has 6 siblings and he is the eldest and he reported he

never felt that his parents gave importance to other siblings than him. The client has friends but

the friends who made him take drugs are not his friends anymore.

A.J childhood had a happy childhood he used to live in Sargodha where he completed his

initial schooling. General home atmosphere was friendly where he made good memories and

friends as per mentioned above he has a good relationship with his family.

Educational History;

A.J completed his school from Sargodha, he was an average student and good in his

studies he also used to participate in extra -curricular activities in school. Client’s relationship
with his peers and teachers was cooperative, later he migrated to Islamabad and completed his

rest education. He has completed his B.S honors.

Occupational History;

A.J was doing a job after his B.S in a private company, he had a satisfying job while he

got addicted to drugs and started using his salary on drugs which he reported that maximum 15k

per month were used on buying drugs. His addiction cost him lose his job later.

Marital History;

A.J was married and have a son, he reported that his wife was very supportive during his

treatment phase he also reported that they didn’t had any major fights but only small arguments

due to his drug taking habits.

History of present illness;

He started taking his dugs with his friends as source of fun initially he used to take

cigarettes later his friends made him take heroine with which he got addicted. He never

overdosed himself with it but it became a need with passing time. He got mentally unstable due

to taking drugs which got treated when his treatment started. No other psychological or

physiological illness was faced by A.J before.

Client reported that his family was very disturbed due to his addiction habit. Client had

very strong relationship with his family and they convinced him to leave that habit. Client

reported he start taking cigarette from his friends and that was huge mistake. But when his

family forced him for treatment, he admitted for treatment to Hero Rehabilitation Centre for the

purpose of treatment.
 Client reported to start severe headache and low and irritable mood, dry mouth,

aggressiveness, low self-esteem, sweating, trembling, restlessness, after not taking drugs. His

sleep and appetite was disturbed too. He reported to feel better after taking prescribed medicine.

Premorbid Personality

Before the onset of his illness, the client was living a healthy life. He had good

relationship with his family and friends. He liked social gathering as well. He was active and

energetic and used to spend his time with family and friends. He had a cheerful mood, he was

helpful in nature he had friends.

Psychological Assessment

Informal Assessment

Behavioral Observation

The client was with long height and normal weight. He was wearing weather appropriate

dress, his mood was euthymic. His talk was relevant. He had appropriate eye contact. He was

cooperative with the therapist whatever was asked he answered it properly and he communicated

well with the therapist.

Clinical Interview

Structured and semi-structured clinical interview was carried out with client. Interview

was conducted to identify client problems, history of present illness, personal history, family

history, education history, occupational history and marital history. The client was cooperative

and compliant during the interview.

Formal Assessment

In formal assessment two psychological test were used DAST and HTP.

Drug Abuse Screening Test (DAST)

The drug abuse screening test (DAST) was designed to provide a brief instrument for

clinical screening and treatment evaluation research. The 28 self-report items tap various

consequences that are combined in a total DAST score.

Quantitative Interpretation: the client answered YES to 11 items and answered NO to 14

items, the total score of client is 11 when being assessed through DAST which shows that the

client has just a mere sensitivity to drug abuse and the client do not have any substance abuse

problem.

Qualitative Interpretation: On DAST the number of yes responses indicated over the

past 12 months the client was using the drug other than those required for medical reasons but

the test shows that the client does not have a problem with drug abuse the problem of abusing

drug exists.

House Tree Person (HTP)

A.J was made to HTP where he drew a house, a male person and a tree which he said that

the house is his own house the male figure is his younger brother and the tree is outside his

house.

House
 The house was drawn on the left side of the page which shows that the client shows

withdrawal, regression, childish behavior, is self-preoccupied and shows rumination over past.

He drew the house first which means he is concerned with sense of belonging, nurturance and

bodily needs. The house is in too little size which shows withdrawn tendencies and rejection of

home life. The doors of the house is missing which shows the client has sense of insecurity and

feels isolation. He drew boundary walls which depicts insecurity. He made small windows and

doors which shows the client might be shy, withdrawn or inaccessible, suspicious or even

hostile. The structure of house is made of weak lines which means weakness of ego boundaries.

The roof is made of single line which means constriction. There were no pathways drawn which

depicts that the client is not social doesn’t share any feelings with others, it indicates the client

may be distant and removed.

Tree

The tree client drew looks like a windblown tree which means the client is under

environment pressure, the tree lacks details such as it has no leaves which means he is at the

phase of withdrawal. He drew branches on every side of the tree which depicts that he has an

obsessive compulsive personality and the branches are small which shows he has limited skill.

The crown of tree looks like dead which shows emptiness/hopelessness in client. The roots of

tree are long with no base which shows insecurity feelings. The tree has a small trunk which

means limited ego strength. The bark of the tree is absent which means the absence of ego

control.

Person
 The client drew same sex figure which shows hysteric and manic tendency as well as

restlessness. The figure is younger than the subject which shows emotional fixation at the age

depicted in the figure. The buttons are made in the middle which means somatic preoccupation,

maternal dependency. The head of the figure is drawn large which shows regression, grandiosity.

Feet are small meaning need for security. Dim hands showing lack of confidence in productivity,

claw like fingers means overt aggression and paranoid. The client drew fingers with no hands

which shows assertiveness, intentional, infantile aggression. Arms are drawn open showing

aggression and the arms are difference in lengths which means conflict in inhibiting some

abilities. Arms are long but weak means dependency and nurturance also thin and weak which

shows lack of achievement. The figure is drawn on the left side of the page which means the

client is self- oriented, shows overt behavior and tension. Eyebrows are drawn curved means

feelings of superiority, proud, arrogant. Large open eyes showing suspicious. The client showed

less emphasis on nose which means weak ego power. Neck is drawn short shows self-indulged,

inhibited. Stick like figure means childish, secretiveness, concrete thinking.

Diagnosis

The client filled the DAST questionnaire which shows that A.J still have slightly drug

abuse problem but it’s not severe. HTP results contradict from some of the statements the client

gave for example he said my family is very friendly and supportive but HTP shows that he faces

rejection at home so the results might not be reliable but most of the descriptions match with the

symptoms of drug addiction. So it can be concluded that A.J might still have problem of drug

abuse and it can be treated through therapeutic treatments.

Prognosis
 The prognosis of the patient’s problem seemed to be favorable due to the presence of

many supportive factors for the treatment.

Points on Favorable Prognosis

 He had insight regarding his problems.

 He had emotional support from his parents

 He had emotional support from his siblings

 He had emotional support from his wife

Management Plan

The client is in withdrawal phase but still shows some symptoms of drug abuse. The

management plan was derived from the fallowing therapies keeping in view the individual needs

of the client and the functional rational of the technique.

Rapport building

To engage the client in therapy and to continue a smooth flow of therapy, rapport will be

built with the client. The level of trust will be actively build with the client through active

listening, unconditional positive regard, and warm acceptance to help him increase the ability to

identify and express facts and feelings. Initially, He will resistant to share his feelings and

thoughts with the therapist. Rapport Building will done with the client in order to create a

therapeutic alliance and to enhance the motivational level in the patient for the compliance and

continuation of the treatment (Milten berger, 2012).The rapport will be developed through

talking and inquiring about hobbies and likes and dislikes of client. The patient reported that he

felt comfortable in the environment provided to him.

Psycho education

It is the presentation of systematic, structured, didactic information on illness and its

treatment. It aims on providing the information about cases, symptoms, and progression of

illness and it reflects in mind body conceptualization of the problem (Power & Freeman, 2007)

Psycho education will be done regarding nature of the problem, cravings, chances of

relapse prevention, and contribution of environmental factors to his illness and realistic picture

regarding its prognosis. He will be told about the importance of self-monitoring and homework

assignment. He will also have told about the effectiveness of medicine.

Relaxation Techniques

Relaxation technique is any method, process, procedure, or activity that helps a person to

relax; to attain a state of increased calmness; or otherwise reduce levels of pain, anxiety, stress or

anger. Some relaxation exercises are:

Progressive Muscles Relaxation (PMR)

In order to deal with anxiety symptoms, the client can be taught how to relax his muscles

and thus achieve autonomic control. To start with, he will be immediately given deep breath

exercise and then trained to relax the 16 group of muscle that results tranquil conscious feeling

accompanied by a reduction in anxiety and a general decrease in physiological arousal. When the

client will be sitting in front of therapist he feel conscious about this technique and ask question

what are the benefits of PMR after listening the question therapist explain the advantages about

muscles tension and then client will perform carefully, after performing this technique he will

feel comfortable and relax due to muscle relaxation. With the passage of time on fallowing

session the client will perform PMR again and again and feeling relax and comfortable.
Deep Breathing

Deep breathing is an easy way to relax and let the client worries go. In which therapist can do

it pretty much anywhere and it only takes a few minutes. The steps are: Find a comfortable, quiet

place to sit. Choose a spot where you know you won't be disturbed. If sitting, to ask the client to

keep you back straight and your feet flat on the floor. Ask the client to close your eyes. Ask the

client to the inhale the breath with nose with the reminder of 1, 2, and 3 seconds and then slowly

exhale the breath through mouth.

Sleep Hygiene

The sleep hygiene principle will be taught to the patient to deal with his sleep

disturbance. Researchers have shown that anxiety can trigger sleep disturbances (Mohr et al.,

2003 & Alfanoet al., 2007). He will be educated to maintain regularity in the sleep–wake

cycle timing, exercise regularly, but not within a few hours of bedtime, develop a relaxing

evening routine, reserve the bedroom and bed for sleep, avoid caffeine after lunchtime especially

within a few hours of bedtime, avoid late heavy meals, but consider a small bedtime snack, avoid

bedroom temperature extremes, avoid disruptive noises and avoid excessive wakeful time in bed.

Cost-Benefit Analysis

Cost & Benefit analysis is a systematic process for calculating and comparing benefits

and costs. This involves making the list of advantages and disadvantages of using drugs and

revaluating drug use overall (Boardman, 2006). This will be done by using a two cell matrix with

the advantages and disadvantages of using the drugs within the session. Initially, the patient

records his own view of advantages and disadvantages but with the help of therapist he will be

able to generate few more significant advantages and disadvantage. This task will be helpful for
facilitating the client to generate the new perspective. When the analysis will be successful the

patient will have a more accurate objective and balanced view of using drug then was previously

held.

Daily Thought Record

Daily thought record will be given to separate intrusions from thoughts. This will be

helpful for the patient to record his thoughts and get to know the intensity of thoughts before the

situation and after the situation. This will also helpful to cope with the thoughts in the current

situation.

Five Ways of Functional Analysis

Functional analysis is the stage of cognitive-behavioral therapy that needs to be learned

in terms of thoughts and feelings because it can contribute to the individual's maladaptive

responses. It has five ways:

 What?

 Where?

 With whom?

 Why?

 What happened?

During the session, firstly the patient will resist to describe these situations and told the

therapist he was uneducated. After, sometime, he will easily describes all situations.

High Risk/Low Risk Situation

 A high risk situation is any experience that causes people to if two things:

1. Move away from the people, places

2. The things that support your recovery

Whereas, a low risk situation is a process in which there is thought to be just a small chance

of losing something. During the session, the therapist will give a worksheet to patient regarding

low risk/high risk situation and will tell him to describe these situations.