Summary

K.H was 23 years old young boy belonged to a middle socio-economic status, brought to

FOUNTAIN HOUSE due to presenting complaints of body pains, low appetite, and aggressive

behavior. Assessment was done by formal and Informal methods. Informal assessment was done

by Clinical Interview, Mental status examination. Formal assessment was done by Mini Mental

Status Examination, Rotter’s Incomplete Sentence Blank ,Alcohol Use Disorders Identification

Test and House Tree Person Test. According to assessment he was diagnosed as Alcohol

withdrawal disorder.Management of this case was based on supportive therapy, psycho-

education, deep breathing, modeling technique used to say NO to drugs, anger management,

sleep betterment techniques and relapse prevention. The client was cooperative during the

treatment and showed significant improvement in recovery.

Biodata

Name : K.H

Age : 23 years

Education : 5th Standard

Gender : Male

City : Vehari

Siblings : 1 sister + 6 Brothers

Birth order : 6th

Profession : Accountant inMadressa

Reason of Referral

Client was referred to the Trainee Clinical Psychologist for the purpose of assessment

and management.

Source of Referral

The client was referred by his father for the treatment of addiction and behavioral

problem.

Presenting Complaints

As reported by client:
‫ن ت‬ ‫ن‬
‫ای ک سال‬ ‫ے۔‬ ‫ٓا ھوں می ں سے پتا ی ٓا ا ہ‬ ‫ک‬
‫ای ک سال‬ ‫جسم می خںت دردی ں ہ و ی ہ ی ں۔‬
‫ئ‬
‫ای ک سال‬ ‫ے۔‬ ‫ہ‬ ‫ب ھوک م ہ و گ ی‬
‫خش‬ ‫ت‬
‫ای ک سال‬ ‫ے۔‬ ‫ے گتال ک رہ ت ا ہ‬ ‫پ ی اس لگ ین ہ‬
‫ای ک سال‬ ‫ت‬ ‫ت‬ ‫دماغ کام ہی ں کر تا۔‬
‫لن‬
‫ای ک سال‬ ‫ہ‬ ‫ہ‬
‫ے چک ھ ج ا ا وں لے کر چک ھ ٓا ا وں۔‬‫نچ یزی نں رکھ کرتب ھول ج ا ا وں۔ ی‬
‫ہ‬
‫تای ک سال‬ ‫ن‬
‫ت‬ ‫غ‬ ‫ت‬ ‫غی د ہی ں ٓا تی۔ ت‬
‫ی ن سال‬ ‫ے و پ ھر سب کو مار ا ہ وں۔ صہ می ں پ اگل ہ و ج ا ا ہ وں چک ھ سجم ھ‬ ‫ن صہ ب تہت ٓا ا ہ‬
‫ہی ں ٓا ی۔‬
 ‫ت‬ ‫ت‬ ‫ق نش لن‬
‫ت ی ن سال‬ ‫ے۔‬
‫ے کو دل کر ہ‬
‫ا‬ ‫ہش ر و ت ن ہ ی‬
‫ی ن سال‬ ‫ے سے سکون ملت ا ہ‬
‫ے۔‬ ‫رابپ ی‬
History of Present Illness

When he was 23 years old he was taking drug in little amount but not taking on regular

basis. Start with cigarette and paan after that one day he has curiosity about the taste of other

drugs so he start taking alcohol for the last 6 years. and now he is dependent on alcohol. Client

reported when he take charas he had no side effects when he start alcohol then he gradually

became weak. His girlfriend left him he started high dosage of drug and start drinking more and

more and now he is addicted of alcohol. Client reported home environment, family members are

responsible of my condition. No one loved me, my brothers quarrel me. All drugs all the time

present at my home. Whenever he wants he take it. Whenever he doesn’t take drugs he was not

relaxed. Everyone seen in bad way, no one respect him. Sister-in-law or other relative criticize

me all the time. He was hurt from others comment about his future life. No one will be accept

to you as own son-in-law. People not respect him. Friends are not come to meet him. No one

invite in his own him. When family member stop him to take drugs then fight with them. All

drugs are in their home. Easily take from home sometimes he stays away from home. Client

reported now a day drugs are not available in good quality. He takes 1 powder then not craving

till 4 days. He was never stole thing from home for taking drugs. Addiction spoils his study. He

was much interested to doing study. His business was finished. Other persons not hire him for

job. He reported that he has stomach problem, appetite disturbed, Pains in all body parts,

memory impaired. He reported my life had spoiled.

Background information

Family History
 Client’s father was a businessman and mother of the client was housewife. Parents’

relations were healthy and they have good understanding. Client loved with his parents. Mother

was so caring and always tells him to stop addiction. Father always guide him about right path

give him strength and encouragement “you are a strong person you have ability to leave the

addiction”.

Client had six brothers and one sister. His sister was housewife and having three kids.

Client loved with his nephews. All brothers doing wrong work supply drugs of different kinds

like charas, heroin, afheem, wine etc. He did not like them. Brothers beat him then client react

back. Client had not congenial relation with brothers.

Home environment

Client belonged to a middle class family. His family system was joint system. Client

reported when he was a child his home environment was congenial. Gradually home

environment become changed. Now home environment was uncongenial. Whole family

members quarrel to each other. No one can bear one another. Sister-in-laws (bhabies) was the

main reason to create issues and misunderstanding between brothers.

Client reported when his brother beat him then he showed react back. All the time his

sister-in-laws criticize him as an addicted person. No one gave you proposal of own daughter.

Client reported he not like his home environment. Every one doing wrong work and earn

unfair money. He takes drug and stay away from home for three to four days. Every time

quarrel atmosphere when ask for food then sister-in-law gave late so then start fighting. He

reported that there was stressful environment in his home he could not get relax at home.

Personal History

Developmental history
 Client birth was normal. He achieved all his developmental milestones at appropriate

age. He was a healthy child. He had no psychological trauma, fever or any accidental history.

Educational history

Client started his schooling at the age of 5 years. He was keenly interested to go school.

He got position till 5th class. His favorite subjects English, math, drawing. He dislikes these

subjects Arabic and Social studies. He was a mischievous student and wandering all the time.

After 5th class, parents stop school and gave admission into Madrasa for the Hafze of

Quran. He was not willing to do but his parents force him then he studied Quran knowledge at

madrasa. I had left madrasa without completion Hafze of Quran due to strict environment.

Occupational history

He was started his professional career at youngest age. Worked as electrician (3 years),

kite maker (3 years), Salesman (5 months) and drug supplier.

Pre morbid Personality

He was a mischievous student and wandering all the time. He liked to make friends and

meet with peoples. He was very social and loveable person. He had many friends. He was

wearing same dresses and go together everywhere. Everyone gave respect, like him. His whole

family loves him. He offered all prayers regularly and recited Holy Quran. He used to playing

cricket, basketball and go with for walk with friends.

Assessment

Informal Assessment

 Clinical Interview

 Mental status examination

Clinical Interview
 The clinical interview was conducted in order to gather information regarding client’s

illness, to develop rapport and to inform and motivate the client for recovery. During interview

detailed information was sought from client and her parents regarding predisposing, precipitating

and maintaining factors of her illness. The nature of stressors was also identified by background

information. During interview her family was asked about her illness, personality factors, and

other important areas were also explored such as sexual aspects, education and social life. This

detailed information and behavioral observation provide enough data for assessment and

diagnostic purpose.

Mental Status Examination

The client was 26 years old young boy. He was tall and weak. His dressing was neat and

clean and proper. He was maintained eye contact. Rapport was easily built. His sitting in

relaxed posture but after sometime he was changed his posture. All the time he grasps his

fingers in other hand. He was shy but cooperative. Client was in euthymic mood but felt some

nervousness and shyness. Client was over talkative. Tone of his speech average and gave

relevant answers. His orientation about person, place and time was alert. Client remote, recent

past memory was intact but he was unable to recall where he had putted things. Client attention

and concentration was alert. He was successfully completed 7 serial test. Client insight was

present. He was aware about his illness and adverse effects of addiction.

Formal Assessment

Formal assessment was done by using:

 Mini Mental State Examination (MMSE)

 Rotter’s Incomplete Sentence Blank (RISB)

 House Tree Person Test (HTP)

  Alcohol Use Disorder Identification (AUDIT)

Mini Mental State Examination (MMSE)

It was used to screen cognitive impairment .It was also used to estimate the severity of

cognitive impairment and to follow the course of cognitive changes in an individual over time.

Thus making it an effective way to document an individual response to treatment.

Quantitative Analysis

Total Scores Achieved Scores Level of problem

30 29.5 Low
Rotter’s Incomplete Sentence Blank (RISB)

RISB is a projective technique which is used for checking the maladjustment. It consists

of 40 incomplete sentences.

Quantitative Interpretation

Score Cut off score

156 135

Qualitative Interpretation

The client scores are high on RISB which showed that he having problem in these areas

of life which that test measures.

Familial Attitudes

Cleitn had good relation with his parents. He showed on item.

11. A mother---------. I like her very much.

35. My father---- is a good man. Love me a lot. Fulfill all my wishes. Client had no

good relation with his brothers and he did not like hi home environment.
 3. I want to know-------- what my brothers doing?

4. Back home-------- when I want to get food no one get it for me because they know I am

wasting food.

9. What annoys me-------- my brothers.

12. I feel---------- my home is disturbing not like that good home I try my home become

well.

15. I can’t ---------- do domestic work. I don’t willing to do.

22. Reading-------- I have interested but my family spoils my future.

24. Future--------- my family not making my future.

31. This place--------- I like this place. I am leaved my family members.

Social and Sexual Attitudes

Client had different issues he fights with friends and he was much annoyed.

General Attitudes

Client showed others people are good. I like to drink milk and the morning time of day.

He liked cricket and want to join Pakistan cricket team.

Character Traits

Client showed superiority element in his personality and he complaints addiction destroy

physical himself.

Conclusion

The results of RISB indicated that client have relation problem with siblings and not want

to live in home because he not like his home environment. He was aggressive but he wants to

change himself or spent good life.

Alcohol Use Disorder Identification Test

The test was used to assess the excessive use of alcohol of the client.

Qualitative analysis

Total scores Cut off scores Achieved score

40 18 High level of alcohol

Qualitative analysis

The client showed 18 scores in alcohol use disorder identification that indicates high

level of alcohol intake.

House Tree Person Test (HTP)

House

The client drew a house on paper which depicted the personality traits of the client.The

client draws a small house in the middle of the paper.This small house is the indication of

withdrawal feelings of inadequacy and rejection of home and life. The roof the house shows the

ego of the client.The window shows that client is interactive with environment. The client

showed overemphasis on the door which indicates a conscious effort to maintain control.

Thedoor is open which emphasizes reluctant accessibility. The path ways towards door indicates

the openness and accessibility to others.

Tree

Amazingly the client drew two trees, one on the left side of paper and one on the right

side. Placement of tree on both sides of page indicate that person has usually imbalanced

receptors to both masculinity and feminist influence and able to relate to both men and women.

The trunk of second tree indicate the strength of his ego. The client drew the roots that seemed to
be touch the ground rather than underground which shows strong paranoid and aggressive

attitude.

Person

The client draw a very large face man with bear and mustache which shows the client

maturity .Large eyes with eye ball indicate that the client was accepting the stimulus. The client

was overemphasized on the head and ears which shows the feelings of superiority ,intellectually

and socially . Ears shows that the client had paranoid tendencies.

Conclusion

Interpretation of HTP reflects that client is suffering from many problems. He was

suffering from inadequacy, inferiority and guilt etc.

Case formulation

The client is 23 years old young boy. He lives in joint family system. He loves his

parents. But he does not like his elder brother and he was much upset from his home

environment. The reason is that all brothers also taking drugs like alcohol, charas and powder.

All these things are available at home. When he was a child then he taste and gradually he

become addict of these drugs. He was disturbed from his life and.

According to USDE (1994) addicts have difficulty with abstract ideas, include cause and

effects. They appear spontaneous to a fault, fidgety, have difficulty following thought on

instructions and organizing tasks. In the case client had difficulty in concentration.

Bandura (1969) expressed that after the person thus become physical depend on drug, he

become very frail and weak and then a person has no wish to do something in his life because he

has also some kind of symptoms. He also cannot go on work and cannot do any thing. Client
showed physical complaints and reported he become gradually weak after the use of heroin and

alcohol.

Learning theorists have long maintained that one of the primaries reinforces for using

alcohol is relief from states of tension or unpleasant states of arousal. According to tension –

reduction theory, the more often one drinks to reduce tension or anxiety, The stronger or more

habitual the habit become(Nevid&Rathus,2007). Client had issue related to home environment

and he get escape from taking addiction to all of his worries.

Hotton (1946) found that the greater the insecurity level of culture the greater he amount

of drug consumption, due allowance having been made for the availability and accept ability of

drug. In this case drugs available all the time at home so availability or excessiveness play

important role in the habitual of addiction.

Environmental and socio cultural factors play a widely varying role in substance abuse

and dependence disorder (Davison & Neal, 2007). Client is much disturb from his life and home

environment.

Diagnosis

Diagnosis:

As per the DSM V criteria, the patient was diagnosed as Alcohol withdrawal disorder

-291. 81(F10. 239 without perceptual disturbances)---.The predisposing factors of disorder was

his bad company and for pleasure seeking .Another factor involved is frustrating home

environment.

Prognosis:

His prognosis was good. The client has full insight of his problem. He is willing to take

proper treatment of his problem. He wants to leave his habit. He appeared to be motivated and
showed his cooperation regarding the treatment. He wanted to live happy life with his family.

There is also a possibility of poor prognosis.

Intervention Plan

 Supportive work was done in order to develop rapport and trust in the client for better

compliance.

 Psycho education regarding to problem, mode of therapy and its goals and procedures

was given.

 Relaxation exercise was taught to counter conditioning rationale to induce physical and

mental relaxation and improve the quality of life.

 Progressive Muscular Relaxation Exercise was taught to keep relax physically and

mentally.

 Cost benefit analysis

 Sleep betterment techniques

 Assertive training through modeling technique ‘say no to drug’

 Anger management through REI

 Aversion therapy helpful for decrease the behavior such as in drug addiction.

 Relapse prevention was focused in the last sessions.

Summary of intervention

Supportive Psychotherapy

The psychotherapy was an important component of therapeutic intervention and a better

start of management plan. It is a common form of therapy that may provide the individual's set of

circumstances. The client needs to be given the opportunity to express their feelings and thoughts
about that issue. The client discusses his problems with therapist after built rapport. And it is an

important part of supportive psychotherapy.

In supportive psychotherapy, trusting relationship a between the client and therapist. It is

important that the client has confidence and the therapist can understand the feelings of the

client. Supportive psychotherapy can lead to improvement the self- esteem. The supportive

psychotherapy is best suited for people who are trying to cope with their problem.

Psycho education

Psycho education was a significant part of management plan. It was also essential to set

the future goal and help the client about his issues. Psycho education refers to the component of

treatment where active communication occurs. The therapist educates him about his problem

symptoms, etiology, and the treatment of the disorder.

Relaxation Exercise Deep Breathing

Relaxation is a process, method and procedure that decrease the effects of stress of client

mind and body, or otherwise reduce the stress or anger. The rationale of relaxation exercise can

help the client to cope with everyday stress and with stress related to various health problems.

The therapist conducts the relaxation exercise to the client through deep breathing, deep

breathing. The purpose of deep breathing was to relax the client from sadness and tension. The

therapist instructed the client to inhale through nose, feel the tension with close eyes. Exhale

breath through mouth and release your tensions and stress after 2 minute.

The client felt very relaxes after relaxation exercise. The therapist asked through 1 to 10

the client told pre-rating was 10 in first session and the post-rating was taking after second last

session the client rate on 07. The therapist gave these exercises as homework assignment to the

client. The client felt much relax after these exercise.

 The benefits of relaxation exercise can reduce stress by heart rate, reducing anger and

frustration, slowing breathing rate, improve concentration, boosting confidence to handle

problems.

Muscles Relaxation Techniques

Relaxation exercise was done to decrease the stress level of the client, and to make him

relax. Initially the client was instructed do not eat or drink anything before exercise and to sit on

chair in relax state. In the first step close eyes and listened the therapist with fully concentrate.

Start exercise with deep breathing.

Muscles relaxation exercise start from the hands and instruct him to tight his fists with

full power and when he feel tightness then open the fists in relax way, the time duration for tight

condition was 5-10 seconds and for relax condition was 10 -15 seconds. The second step was

elbow, the therapist instructed him to tight his elbow for 5 to 10 seconds then relax elbow

withvery relax way. As this procedure was repeated with shoulder, neck, eyes, mouth, chest,

belly, feet, and legs one by one with same procedure. All body muscles get relax of the client.

Cost Benefit Analysis

The therapist asks the client about cost and benefits of alcohol use in his life. He told that

his behavior is harmful. The reason behind to be aware about alcohol use.

Sleep Techniques

The proper amount of sleep is necessary for the client sufficient amount of sleep is also

needed for the healthy living of a person. Some cognitive and behavioral methods that can be

tried for restoring healthy sleep patterns are:

 Following the regular sleep patterns and going to bed just when one is likely to feel

sleepy.
  Associating the body cues with sleep, such as listening to a favorite soothing song about

fifteen minutes before one is scheduled to retire.

 Another method could be to use relaxation as a sleep aid. Relaxing muscles creating

relaxed images can help dull some of the sharp edges of sleeplessness.

 Messaging feet for ten minutes immediately before going to the bed can also be effective.

 When one is unable to sleep, a tested behavioral approach is to get out of the bed. The

idea is to avoid associating the bed with wakefulness. Return when one is ready to sleep.

 Counting backward from one thousand by threes can also help in improving sleep

patterns.

Assertive training through modeling

Modeling can also be recommended as a behavior therapy program. In the course of

training, the client is the encouraged to respond as the therapist models appropriate behavior so

that the client can observe it and be able to imitate it. In this way a combination of modeling,

role-playing and positive reinforcement can bring about significant improvement in the client’s

interpersonal behavior.

After treatment client go back to hone, he has to refuse his friends from addiction. Client

has to told that when he go back home increase chances of relapse. His addict friends meet to

them. Sometimes on road, home or other places, and in that condition how client has to deny

himself from addiction.

One play the character of addict person and other one play the character of client who is

going back to home after treatment and does not want to do addiction. But his addict friends

come to his home to meet him.

Anger management through REI

 Rational Emotive Imagery is one of the core emotive and experiential techniques used in

REBT approach, was modified by Ellis in 1966 and it was taught to the client to think rationally

and to deal with unhealthy emotions in imagery level and can be able to feel more healthy

emotions in real life.

In the present case, REI was used to teach the client anger management. The rationale

was to train the client to use imagery to increase self-control in future anger provoking situations.

The client was asked to close his eyes and place himself in a recent difficult situation in

which experienced this dysfunctional emotion i.e of anger. He was asked to raise his finger

when he had vividly imagined both the situation and the upsetting emotion. He was asked to

label the emotion and rate its intensity. Then he was asked to focus on changing the emotion of

anger to a more reasonable, healthy and functional negative emotion of “annoyance”. He was

asked to raise his finger if he was able to do this. He was also asked to rate his emotional

distress. Then was invited gradually to return to the present and open his eyes. Then the client

was asked how he was able to change anger into less intensity emotion. The client reported that

he was feeling annoyance. He associated his changed thoughts by using coping statements which

helped to decrease the intensity of his anger.

Aversion therapy

Aversion therapy helpful for decrease the behavior such as in drug addiction client have

craving, this technique used to control the craving. In which behavior is coupled with unpleasant

experience. It is very helpful for avoiding the using drugs due to its disgusting feeling.

Relapse prevention
 Relapse prevention was focused in the last sessions. The client was asked about what he

had learnt during the treatment and all of the concepts were revised by considering the fact that

at times, the rationale still remains not grasped completely.

Session Reports

Total 12 regular sessions were conducted with the client.

Initial session report

In the first 2 sessions detailed information regarding the client’s history was gathered.

Focus on rapport building. These sessions were based on hope restoration in client the main

purpose of these sessions was catharsis of the client regarding to client problem.

Middle sessions report

In the middle Assessment of client’s problem completed through formal and informal

tests in order to better understand the client issues. Relaxation exercises were taught to client for

relax himself in stressful situations.

Interventional sessions report

In this phase different techniques were taught to deal with her problem. Management was

conducted related to addiction and anger. In the last sessions relapse prevention was done and

bibliography material was provided. At the end encourage client to join follow-up sessions if feel

problem in future.
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