19

Identifying Data
Name : U.Z

Gender : Male

Education : F.A

Marital status : Divorced

No. of Siblings : 9 (4 sisters, 5 brothers)

Birth order : 7th

Family system : nuclear

Economical Status : Middle class

Informant : Client

Ward : In Patient

No. of session : 9

Initial date of Seen : 07-03-2018

Date of Terminate : 19-04-2018

Source and Reason for Referral

The client was referred by institute clinical psychologist to the trainee clinical
psychologist for the assessment and management of the client.

Presenting Complaints
Table 1
Presenting Complaints of the Client as Reported by the Institute’s Clinical Psychologist
Duration presenting complaints
‫پچھلے دو مہینوں سے ٹیکے لگاتا ہے‬
‫چرس پیتا ہے۔‬
‫پاؤڈر بھی پیتا ہے۔‬
‫سامان چوری کرکے بیچ آتا ہے۔‬
 20

Initial Observation
 21

U. Z was 37 years old male with age appropriate height and weight. The client
was observed through participant or non-participant observation. Non-participant
observation was done during the group and participant observation was done during
individual session. During the non-participant observation it was observed that he was
wearing neat and clean clothes and his hair was properly combed and nails were clean
and properly trimmed. Client seat properly on the chair and in relaxing posture. His
speech was clear, volume was appropriate and content was relevant but due to medication
he had problem while talking. He participate in group time to time. He used to interact,
communicate and spend time with the members of the ward. It was observed during the
individual session the client establish and maintained the eye contact. The client seemed
to be well mannered as he greeted the therapist in start and say good bye and Thanks at
the end of the session. The interaction of the client with the therapist was very
cooperative as he responded and showed compliance towards the therapist. Trainee
clinical psychologist ensure about the confidentiality whenever needed. Client seems to
be very motivated for his betterment and treatment. Client have insight about his
problems and its consequences because he relapse 2nd time. Before coming to this
institute he was admit in another institute where he faced many problem. Now client is
very motivated to leave the drugs. He showed interest during the session. He was also
willing for the next session and was also asking about the next session schedule as
rapport was established with the client because of his cooperative behavior and insight
about his problem.
Development History of the Problem
 22

According to the client when he was in 5th class. He was with his elder cousin in
home alone his elder brother was also with him. Due to the absent of his parents his
cousin forcefully sexually abuse him. At that time he feels pain but he forget that
incident. After reaching to the puberty age, than he realize that what happened with him
in childhood. He feels guilt but he didn’t tell anyone but his elder brother also know
about that incident. He want to forget that event. When he comes in class 10th. They bunk
from school and go to park, where his friends offered him a cigarette. Firstly he denied to
take cigarette but after forcing by his friends. He smoke cigarette but he cough after
smoking. After that event, he start smoking occasionally and after giving final exams
they start smoking regularly 5 cigarette per a day. After passing out in the class 10th
paper. He got admission in a government collage, when he comes in collage he start
smoking 1 pack of cigarette per day. But after passing out in first year, he go to a party
with his friends. Where his friends offered him a cigarette of hash, he take the cigarette
and feel good after smoking that cigarette. There he made new friends, those who live
near to his home and they were the regular user of hash. After that, before going to
academy he meet with his new friends and smoke a cigarette of hash. After one month he
becomes the regular user of hash. His friends and he contribute the money and buy hash.
He failed in final exams of 2nd years than he decided not to study anymore and start
working in his brother’s factory. Now he had enough money to buy drugs. One day his
friend take him to a place, where they had assess to prostitute. Then he and his friend
contribute their money and had sex. During that time one of his friend start using heroin
and asked him to use it will increase your sex timing. Firstly, he denied to use the heroine
but after few week. He use heroine for the first time and he had pleasure after using the
heroine, after than before sex he use heroine. After that client said he had not appeal of
sex but he starts cravings for heroine, he use heroine for 3 years. One day, he was going
to attend his friend’s wedding. Who was crescent by religion where he met with a girl
and falling in love with that girl, his relationship start and he married with that girl in
court with the help of his friends. According to client, he married to that girls because girl
wants to change his religion and also she loved him very much, but when they knew
about their marriage, the client’s parents got disappointment but they accept their
marriage but client was living in a rent house. According to client girl’s mother not
 23

accept their relationship and his mother and her brother thread him and his family. They
will kill them and their family too. After 8 month of marriage he get divorced from his
wife. According to client during this relationship. He didn’t use the heroine but him only
use hash and he start reducing the quantity of those drugs, but after getting divorced. He
start consuming the drugs again and increase the quantity of drugs. He lose many jobs
due to his addiction. Client also mentioned that during these phases of his life, he had
rage for his cousin and he always him he was the reason of his condition. Now client
want to forget those events and he forgive his cousin and want to start his life again as a
healthy person and want to serve his father.
Background Information
Personal history. Client is a socialize person. He love to interact with other
person. He follow the daily schedule of the institute. He was admitted in this institute 1
month ago. The client wake up early in the morning. He offered prayer and recite the
Quran. After that he lay down on his bed and get up from his bed at breakfast time. After
eating breakfast of medicine. He go to television room and watch Television. He had not
favorite channel. He watch whatever show or movie was playing on Television. After
that he eat his canteen and he lying down his bed and talk to his friends. He offered five
times prayer. He like to play cricket but they cannot play cricket indoor. Other games like
ludo, cards etc. other clients played he didn’t like to play that game but he watched them
while playing. He always try to busy himself in different activities. If he had a physical
problem or any problem he discuss with his friends and attendant.
He also motivate other person to leave the drugs and he also discuss with his friends what
he learn in session.
Premorbid personality. Before starting these problem. Client was very socialize
person but after sexually abuse by his cousin. He start to avoid a social gathering, but
after taking admission in academy, he start socialize again. He was very friendly to
everyone. In childhood he was much pampered child, every one love him and he had a
good relation with his father because his father fulfil his all wishes. He also reported that
he takes part in different extracurricular activities like cricket, wooly ball, and football.
He play other different games but he like cricket the most, he and his younger brother
was played together and he was the captain of the team.
 24

Family history. The client live in nuclear family system and belonged to middle
class family. The client father is 85 years old. He done metric and he was a government
servant. He was the authoritative person in the family. Client have congenial relationship
with his father. Because he was 3rd last children and father like him more and fulfil all his
wishes. His father belonged to a village. He used to smoke cigarette and Hookah. His
father was the dominant person in family and impose his decision in family.
The client mother was 60 years old when she died and she was a house wife. She
was uneducated. Client have a congenial relation with his mother. She always take care
the client, and always trying to made client’s favorite food. She always help the client
when he stuck in any difficulty. Client always ask his mother for extra money. Client’s
parents shared a healthy relationship with each other, and all the important decision were
taken by the mutual concern of father and mother.Client have nine siblings. 5 brothers
and 4 sisters. All of them are married except his younger brother. Client’s relationship
with his brothers and sisters was interactive and loveable. He like his younger brother and
sister the most and he spend most of his time with them. But all of his brother and sisters
are very supportive towards client. As his brother got married they separate their kitchen
and 2 brother change their houses. Client always spend more time with his younger
brother, they play cricket together and shared their thoughts or feelings with each other.
But after when client become an addict, his sisters start avoiding to coming to their home
because they had fear of clients. The client start stealing things from home and shows
aggressive behavior towards his sisters. But client 6th elder brother and his younger
brother always take care of him. He always lend money from his elder money. They give
him money because they didn’t want his brother feel ashamed in front of others or
begged money from others.
 25

Sexual history. He achieved puberty at the age of 14 years. Client’s reaction

towards achieving puberty was normal. There were no disturbances or doubts of the
client related to his pubertal life because he already knew about these changes from his
friends. He reported that he was sexually abuse by his elder cousin. The sexual abuse was
done only one time but that impact was for very long time. He had many sexual
relationships with prostitutes. For the purpose of increase the timing of sexual activity, he
start using heroine. Before that he only use hash. After marriage his sexual relationship
with his wife was satisfactory. After marriage he had no extra affairs or had no
relationship with any other girl.
Educational history. Client start study when he was 4 years old. He was an
average student in the school. He done his matriculation with 60% marks and done FA
first year with 45% and got supplies in 2nd year after that he leave the studies and start job
at his brother’s factory.
Occupational history. After leaving school client was working at his brother’s
factory. According to client he was satisfied and adjust at that factory. But due to his bad
habits of taking drugs, his brother told him to not to come in factory. After that he
changes three jobs. He was not a regular person at jobs, that’s why he got fired from
those three jobs. Before coming he was working in metro store but he left the job due to
personal issue. During these years most of the time, he was free and his brother take care
of him financially.
History of Psychiatry/ Medical Illness
No any psychiatry or medical history was reported in his family.
Provisional Formulation
On the basis of available information and behavioral observation it can be
hypothesized that client’s was physically abuse in his child hood, genetics and family
environment was the predisposing factor of the client’s problem. Which was further
precipitate by peer’s pressure, getting divorced and problem was maintained by low
motivation, past accident and conflict with family. Protective factors was in this case was
client’s motivation and family support.
Assessment
 26

The psychological evaluation of the client was done in order to gather information
regarding their background, nature of symptoms, their causes and maintenance of factors
in order to assess and manage the problem. Following modalities were used for the
assessment of the client.
 Behavioral observation
 Clinical interview
 Mental status examination
 Motivational scale
Behavioral observation. Behavioral observation used to gain a better
understanding of the frequency, strength, and pervasiveness of the problem behavior as
well as the factors that are maintaining it (Ellain, 2014).
The client was observed during the session and the group activities. Client was observed
in different dimensions including, appearance, hygiene, speech, gestures, posture and
attitude towards others.
During observation it was observed that client was most of the time sit quietly during the
group but he was a social person. He recite the holy Quran and offered five times prayers
daily. Hi self-hygiene was appropriate, he wears neat and clean cloth. His hair was
combed and nail was trimmed. He helps the other clients in their work and also shared his
knowledge with them.
Clinical interview. The purpose of clinical interview is to assess what types of
problems the client is dealing with. And also interview is a way to gather information to
help determine the appropriate course of treatment (Ashley Miller, 2017). The clinical
interview was conducted with the client. At first the rapport was developed by talking
about his likes and dislikes and routine. Different areas were probed during the clinical
interview including sexual desires, history of present problem and family’s attitude.
Client was asked about the significant events that disturbed him and leads towards his
problem. The clinical interview was also conducted with the institute’s clinical
psychologist. Presenting complaints were taken, daily sessions, treatment plan and
history was discussed with the institute’s psychologist.
Mental status examination. Mental status examination is the assessment of the
person’s subjective report and experience as well as the therapist’s observation during the
 27

session (Cohen, 2000). The purpose of using this modality was to observe and assess the
appearance, behavior, attitude, memory, mood, thinking, judgment, etc of the client. No
physical deformities were observed in the client. He was maintaining his hygiene like his
clothes was neat, nails were trimmed and teeth were brushed. His motor movements were
coordinated and balanced. He seemed to be very friendly and cooperative with the
members of the wards. He was not hesitant in maintaining the eye contact. The questions
were asked about his family, friends and past events that showed that he was able to
recall the events from memory. During the clinical interview, client was asked about his
mood and then facial expressions were observed. The response and expressions of the
client were matched and this showed that mood was congruent. Rapport was built by trust
building, mutual attentiveness and empathy. He was aware of the orientation. Questions
were asked about the person, place and time and he responded accurately. Hallucinations
and delusions were not present. Client was aware of his problem and its consequences,
hence insight was developed.
Motivational scale. To assess the client’s motivation towards his betterment;
scale was made that consists of 10 points (0-10). 0 means low motivation and 10 means
highest motivation. The purpose of this scale was to assess the client in the initial level of
the sessions and then to increase motivation through different techniques and therapies.
This motivational scale was beneficial in recording the progress of the client. For the
assessment purpose, the rating of the client was taken in the 1st session that was 4. Client
was asked about his rating that why he choose 4. Client reported that he had no reason to
quit drug taking behavior earlier. He wanted to continue his behavior for his own self and
satisfaction. Because he not forget about past incidents.
10
0
Case Formulation
The client was 38 year old male. The client was referred by clinical psychologist
for the purpose of assessments and management of his problematic behaviors. The
presenting complaints were reported by the institute clinical psychologist are use hash,
use alcohol, use heroine, and use heroine injection.
 28

The client’s case formulation was based on bio-psycho-social model. This model
explains the biological, psychological and social causes acting as predisposing,
precipitating, maintaining and protective factors in client’s presenting problems.
The one of the main predisposing factors was the personality trait. According to
Alan (1983), an addictive personality refers to a particular set of personality traits that
make an individual predisposed to developing addictions. People who have addictive
personality are most likely to involve in risk taking behaviors and find it difficult to
follow rules and maintain discipline. Another main factor was which predisposing this
behavior was client’s father use to smoke hookah, according to a research children whose
parents smoke are more likely to start smoking themselves, (T Devita jr, 2016).
According to Teusch, (2001). There is a long-term effects of childhood sexual abuse can
induced depression anxiety, sucidality, victimization, substance abuse and other
addiction. They will have low self-esteem and broken interpersonal relationships.
Psychodynamic theory states that events in our childhood have a great influence
on our adult lives, shaping our personality. Events that occur in childhood can remain in
the unconscious, and cause problems as adults. Psychodynamic theory clearly describes
the connection of client’s childhood with his sexual abuse and not have moral support.
The client was influenced by his peer in the School. The peer group influence
could be taken as the precipitating factor. Client used to smoke on and off with the school
friends but after going to collage his smoking habits was increased. Client also revealed
that he take the drugs to enjoy the moment and cope up with his stressed.
According to Bandura, people tend to observe, retain and recall from their
environment.
 29

This social learning model of Bandura describe that client when felt relax and
calm and pleasure seeking he was motivated to continue this behavior and repeated with
the passage of the time.

Observation Unhealthy Behavior

Repeated Learned Positive Outcome

Another precipitating factor in this case was client get divorced due to the death thread
from the girl’s family. Which precipitate the client problem. According to Tay, (2015).
After breaking the relationship people start abusing drugs in rage. They hurt themselves
in order to shows other the pain he is suffering from it all due to you. And another
research results shows that some people start taking drugs after breaking up in order to
reduce their pain and relax themselves from the memories of their partner, (Meadow,
2016).
The maintain factor in this case was client relapse, thinking about his past event,
not moral support low motivation and family conflicts.
 30

There were some protective factors of the client that may lead to his betterment.
These protective factors were the client’s cooperative attitude during the sessions and
brother’s consult with the client
Prognosis
The client’s prognosis seemed to be favorable because there are more protective
factors than risk factors. Client’s increasing motivation, cooperation with the therapist
and client’s compliance could be taken as protective factor. The risk factors could be the
past experience and peer’s pressure.
Suspected Problem
According to client history, observation and assessment the client had multiple
drug induce behavior. It might be saying that client fulfil the criteria of Cannabis
withdrawal 292.0(F12.288) and Stimulant Withdrawal (F14.23).

Intervention Plan
On the basis of history and assessment of the client following goals were selected
for the client’s management.
Goals
 Rapport was built by using the techniques like mutual attentiveness and empathy
with the purpose of having trustful and harmonious therapeutic sessions with the
client.
 Psycho-education was done through the technique of case conceptualization for
the purpose to help the client in understanding all the possible factors that lead
and maintained to his current problem. Disease concept was also given to the
client by showing the cycle to help him understanding the chemical change and
 31

nature of the drug and its side effects. In addition to disease concept, client was
also informed about the drug cycle with physical and psychological symptoms.
 Disputing was done for the evidences of all triggering factors.
 Motivational scale was made to take rating on scale after some session’s and
management plan to record the progress of the client.
 Cost and benefit analysis of addiction was done that was helpful in changing his
perspective about continuation of the drugs.
 Reviewing the handling of past negative events technique was used and done in
simple steps to identify the coping styles of the client.
 Relapse prevention was done through client’s own vicious cycle of addiction and
with three C’s of addiction.
 To increase client’s motivation and self-esteem, list strengths and achievement
activity was done with the client.
 Future goals were made and also identify with the client the things that hinders to
his goals and also how he will manage.
 For the peer’s pressure client was taught about the assertive training and also role
play and role reversal and role rehearsal.
These goals were implemented by using different techniques and strategies.
Intervention Strategies
Each goal was achieved by the implementation of one or more technique.
Rapport building. Rapport forms the basis of meaningful, close and harmonious
relationships between people (Dengen & Rosenthal, 2003). It's the sense of connection
that you get when you meet someone you like and trust, and whose point of view you
understand. It's the bond that forms when you discover that you share one another's
values and priorities in life.
Mutual attentiveness. The rapport was established with the client by mutual
attentiveness. It is the way of building rapport where each partner indicating their
attentiveness to the other. This attentiveness may take the form of nonverbal
attentiveness, such as looking at the other person (Zhao et. al, 2014). The client was also
asked about his likes and dislikes, family and free time activities. Mutual attentiveness
continued to the all sessions that enable the client to have trust on trainee.
 32

Empathy. To build a rapport it is very important for the trainee to understand the
emotional sensitivity of the client. Making an effort to be there with and for the client,
and trying to see how the client feels about and sees things (Kelly &Lees, 2013). This
was helping in better understanding the emotional pain and its intensity that the client had
experienced. The client discloses his feelings and thoughts about his family.
Rapport was established because client was following the commands, maintaining
the eye contact and responding to the trainee clinical psychologist appropriately.
Psycho-education. Psycho-education refers to the process of providing education
and information to those seeking or receiving mental health services, such as people
diagnosed with mental health conditions (or life-threatening/terminal illnesses) and their
family members ( Baumal et al., 2014). The purpose of psycho-education was to aware
client about the chemical change and the dependence.
Case conceptualization. The case conceptualization (sometimes called a case
formulation) is the clinician's collective understanding of the client's problems as viewed
through a particular theoretical orientation; as defined by the biological, psychological,
and social contexts of the client; and as supported by a body of research and practice that
links a set of co-occurring symptoms to a diagnosis and, ultimately, a treatment plan
(Fulkerson, 2015). The case conceptualization helps client to better understand that how
the problem started, how it gets worse and why it is maintained.
The client was provided with the worksheet, where all the possible factors were
mentioned. See appendix
Disease concept. For the client with addiction, it was necessary to psycho-educate
him with the disease concept of his problem. Client was psycho-educated that addiction is
a disease and it affects the brain.  The beginning is marked by the struggle for control.
But as time goes on, control becomes increasingly difficult to achieve. Eventually, it is
attained only by quitting.
Client was psycho-educated that drug control the brain activities and then an
individual became dependent on it. Client was given the worksheet.
 33

The drug changing the brain’s structure and chemical was shown to the client by
this diagram. Client was further tells about the craving and concept of the tolerance, brain
dependence and reward or pleasure seeking principle of the drugs.
Drug cycle. After the disease concept client was also psycho-educated about the
drug cycle with physical and psychological signs and symptoms. This was helpful in
awareness of client about his condition.
Cost and benefit analysis. Aron Beck gave the cognitive behavioral therpay and
cost benefit analysis (CBA) is a standard tool used in Cognitive Behavioral Therapy
when people are weighing the pros and cons of change. It is also sometimes referred to as
a decisional balance sheet.
The client was asked to write all the possible benefits of his addiction and also all
the possible negative consequences. See appendix
There were more costs than the benefits, also the long and short term side effects
were also discussed with the client. Client was further asked about the side effects that he
had experienced. The most common side effect client reported was the weaken immune
system. Client participated in this activity and showed positive response.
Goals listing. This activity was done under the relapse prevention to increase his
motivation and determination. Client was asked to write his future goals and then all the
possible factors that hinder your goals. When client write his goals and factors that hinder
it, the main hinderers were his craving and addiction. Client was then asked to keep in
 34

mind the three C’s of the addiction that was mentioned earlier in relapse prevention.
Worksheet in appendix
Motivational scale. After the assessment of the motivation in the first session that
was 4, client was asked to rate his motivation in 4th session and 8th session after
management. Client rate motivation and questions were asked like what is you
motivation in this scale, why you rate this, what you have learn, how you will continue to
maintain it? Worksheet in appendix
The motivation of the client increased from 4 to 6 in the 4th session and then 6 to 9
in the 8th session. See appendix
Reviewing the handling of past negative events. This is one of the techniques of
the CBT, and it is used to review all the past coping strategies to handle the negative
events. The purpose of the technique was to increase the motivation, self-esteem by
discussing about his ways of handling the situations.
This technique was done in simple steps. Client was asked to enlist the negative
events, client reported his craving. Then he was asked that how you control craving and
suppress your need of drug. Client responded that when he wanted to suppress his need
he used to go for cricket match to divert his attention from the thoughts. He used to go in
mosque and spend time there. Then in the last after discussing the coping styles of the
client, he was asked that how he will manage his craving in future. Client was asked to
utilize one of the best coping strategy to cope with it.
Relapse prevention. Relapse Prevention Therapy (RPT) is a collection of
interdependent techniques which are intended to enhance self-control ( Lehn.2016). the
client had experienced multiple relapses so this was important to done relapse prevention
with the client. The client was at first given with the worksheet where his relapse cycle
was drawn. Client was informed about his relapse cycle and also he was informed that
where he should control his self. See appendix
After the cycle of client relapse, client was taught about the three C’s to control
the addiction. These were Control, Compulsion and Chronicity. Control means client
have to control his craving, needs and desires. Compulsion means client should avoid the
drug seeking activities and chronicity means that if client control his desire and drug
seeking activities he will tend to be relapsed again. Worksheet was attached in appendix
 35

Assertive training. Assertiveness training is a form of behavior therapy designed

to help people stand up for themselves to empower themselves, in more contemporary
terms. Assertiveness is a response that seeks to maintain an appropriate balance between
passivity and aggression.
The purpose of this technique was to help the client to have healthy
communication with the family. And communication leads to change and relationship
building. Client was very social person thorough assertive training and role rehearsal
techniques he learned that how to say no to those friends who offered you drugs Client
was trained through role rehearsal and role reversal technique.
Role rehearsal. This technique was used to help client in rehearsing his role with
the friends. Client was asked to take one event and then play his role with the friends.
After identifying the communication style of the client. He was then asked for role
reversal. In role reversal client play a role of himself and trainee clinical psychologist
plays a role of his friend. Worksheets in appendix
After role rehearsal and role reversal, client asked to practice and repeat in next
session.

Termination of the Therapy

Termination is the final stage of therapy and marks the close of the relationship.
Termination is the therapist and the client ending the therapeutic alliance. The
termination stage can be as important as the initial stage in that it is the last interaction
many clients will have with the therapist (Miller, 2000). Client was asked about the
termination of the session in the 2nd last session. Client was asked to review all the things
that he have learn during the sessions and what were the things that helped him
increasing his motivation. Client reviewed all the activities of the sessions and responded
that he became aware of the consequences of the long term addiction. Further client
elaborated about the assertive training that it will help him in better and effective
communication and relationship building.In the last session client was asked to give the
feedback to the trainee clinical psychologist about the sessions and therapies. Client gave
the positive feedback to the trainee clinical psychologist.
 36

Outcome
Motivational scale was taken as the progress of the therapies with the client. In
different sessions, after therapies, client was asked to rate his motivation. There was
increase in motivation from 40% to 90%. The client’s low motivation was maintaining
his behavior of addiction so it was necessary to focus on his motivation of the betterment.
Pre and Post Ratings of Clients
Symptoms Pre-rating Post-ratings
Rapport building 6 10
Psycho-education 4 9
Motivation 4 9
Assertiveness 3 8

Pre and post rating

10
9
8
7
6
5
4
3
2
1
0
rapport psycho-education motivation assertiveness

pre-rqting post-rating

Limitations
 Unavailability of proper place for taking sessions.
 Time miss-management for taking daily session with client due to the schedule of
the Institute.
 37

 Unavailability of family members to gather complete information related to client.

Recommendations
 There should be proper place for taking sessions, so that client may not distract
during session activity.
 Time schedule should be organized, for taking day to day sessions with the client
for his better treatment.

Session report
Session1
The first was aimed at building a rapport with the client. Paraphrasing and mutual
attentiveness was used.
Session 2
History was taken from the client in detail.
Session 3
Client’s motivation rating was taken and also history was taken.
Session 4
Client was psycho-educated about the disease concept and the factors that
maintained it. Further future goals were made for the client.
Session 5
Disputing was done for the evidences of all triggering factors. Motivational scale
was made to take rating on scale after some session’s and management plan to record the
progress of the client.
Session 6
Cost and benefit analysis of addiction was done that was helpful in changing his
perspective about continuation of the drugs.
Session 7
Reviewing the handling of past negative events technique was used and done in
simple steps to identify the coping styles of the client. Relapse prevention was done
through client’s own vicious cycle of addiction and with three C’s of addiction.
Session 8
 38

For stopping the peer’s pressure. Client was taught about the assertive training
and also role play and role reversal and role rehearsal.
Session 9
Feedback was taken and revised all the therapeutic work of sessions.