Table of Content

Content Page No

Case 1

Case summary

Identifying data

Reason of Referral

Presenting complaints

History of present illness

Background information

Psychological Assessment

Diagnosis

Case conceptualization

Case formulation

Management plan

Therapeutic sessions

References

Case summary
The client Mr. M.A was 11 years old male belonged to the middle socio economic status. He has

one sibling only. He was admitted as an indoor patient at mayo hospital with the complaints of

restlessness, irritability, fatigued, sleep disturbances, difficulty in controlling worry and fear

from dark, pseudo visual and auditory hallucination. He was referred to present clinical

psychologist for the purpose of psychological assessment. Psychological assessment was done

on formal and informal level to get insight of the problem. Informal assessment was done by

using Clinical Interview, Mental State Examination, Subjective Rating Scale and Dysfunctional

Thought Record. While formal assessment was done using SDQ, BAI, SCARED, HTP. After

complete formal and informal assessment he was diagnosed with Generalized Anxiety disorder

300.02 (F41.1). Twelve sessions was conducted with the client. The management plan was

based on his presenting complaints. Client functionality was improved.

Bio Data
Name M.A

Father name S.K

Age 11 years

Gender Male

Religion Islam

Education 6th grade

No of Siblings 1(brother)

Birth Order 1st

Socioeconomic Status Middle class

Informant Mother

City Lahore

Presenting complaints
 ‫‪Table 1:‬‬

‫‪Showing presenting complaints and duration.‬‬

‫‪As client reported‬‬

‫‪Duration‬‬ ‫‪Symptoms‬‬
‫ش‬
‫‪From 6months‬‬ ‫می ں پری ان رہ ت ا ہ وں‬
‫ت‬
‫‪From 4months‬‬ ‫ے مگر ج لد ہ ی اکت اہ ٹ ہ و ج ا ہ‬
‫ے‬ ‫ی‬ ‫کام می ں دل لگت ا ہ‬
‫ت‬ ‫خ ن‬ ‫خ‬
‫‪From 4months‬‬ ‫می را ود پ ہ ا ت ی ار ہی ں ہ و ا‬
‫ئ‬
‫ل‬ ‫ج‬
‫‪From 4month‬‬ ‫۔ سم می ں می رےگآ گی ہ و ہ‬
‫ے‬ ‫ی‬

‫ت‬ ‫چ ین خ‬ ‫ت‬
‫‪From 2 months‬‬ ‫ے‬
‫ہ‬ ‫ا‬ ‫مار‬ ‫ں‬ ‫ی‬ ‫کو‬ ‫وں‬ ‫را‬

‫ن‬
‫‪From 15days‬‬ ‫ا دھی رے سے ڈر لگت ا ہ‬
‫ے‬
‫ت‬ ‫ت‬ ‫ن ن‬
‫‪From 15days‬‬ ‫ِا سا وں کی طرح چ یزی ں کہ ی ہ ی ں ہی ں مار دی ں گی‬
‫م‬

‫ت‬ ‫ُا‬ ‫ئ‬

‫ے ت و ب ہت لد جل‬
‫‪From 15days‬‬ ‫ے‬
‫ہ‬ ‫ی‬ ‫و‬ ‫ہ‬ ‫ھن‬ ‫ج‬ ‫ہ‬ ‫ک‬ ‫ھ‬ ‫ج ب ب ھی کو چ‬
‫ک‬ ‫ی‬
‫ت‬ ‫ن‬ ‫ن‬
‫‪From 15days‬‬ ‫ی ن د س ہی سے ہی ں آ ی‬

‫ئ ت‬
‫‪From 15days‬‬ ‫آوازی ں س ن ا ی دی ی ہ ی ں‬

‫‪History of Present illness‬‬

According to the clients mother his problem started when he was 10 years old his parents daily

fights end in the separation of his parents due to which he became very sensitive. He developed a

fear of being alone. He did not sleep at night because of overthinking. He had several

nightmares.

Then after 3 months of this incident he left school because he did not pay proper attention to

the studies and frequent complaints from teachers that he did not listen to the lesson. His mother

taught him at home and kept him remain busy to avoid him from stress. His mother reported that

he often scream at night and do not sleep well and had persistent headaches.

Client reported that his grandmother and father scolded and abuse him when his mother was

not at home so he became very stressful. Client had no permission to play with his friends,

cousins and to ride a bicycle due to which he cried for several times and became frustrated.

His mother also reported that he see multiple time black magic things at washroom which are

very stressful to him. He fear from dark and do not stay alone at home. Mother also had very

strong believe in black magic.

Due to his mother serious illness he had frequent horror dreams and nightmares. He is very

anxious about his mother health, studies and near future.

History of medical illness

The client had no medical history as reported by his parents.

History of Psychiatric illness

Patient had no previous psychiatric illness as reported by his parents.

Birth History (Personal History)

Client was born through full-term normal delivery. There was no neonatal complications.

Mother's age at the time of conception was 23 years. She did not suffer from any complications

at time of delivery. Prenatal and postnatal period was normal. His first cry was immediate. Client

did not suffer from any of the complications even after birth. He achieved all of his

developmental milestone at an appropriate age except to talk in phrases in which he was delayed.

He started neck holding at age of 3months. At the age of 6months he sits without support. He

attained speaking single meaningful word at the age of 12 months. At the age of 4years he

speaks 2-3 sentences. No history of physical illness, and child abuse was reported during the

clients childhood period.

Developmental milestones

Table 1.2

Table shows the significantly delayed milestones of the client: (seleigman & Rider, 2010)

Developmental Milestones Normal Age of Achievement Client’s Age of Achievement

(Seigalman & Rider,2010)

Social Smile 1- 4 months 2 months

Neck holding 3 months 3 months

Sits w/o support 5 -10 months 6 months

Stands w/o support 9-11 months 9 months

Walks without support 10- 15 months 11 months

 Talks in single word 6- 12months 2 years old

Phrases 2- 3 years 4 years*

Complete Sentences 3-4 years 4 years

Eating without help 3 years 3 years

Toilet Training 3-4 years 4 years

*significantly delayed

Remarks: According to mother, client had no fixated diet patterns and limited food items. His

bedtime routine was scheduled, and his sleep patterns were normal. His self-help skills were not

delayed and he does not need assistance in eating, dressing up and in using toilet. His hobbies

and leisure time included playing cricket with his younger brother and to watch video games.

Family History

He was a first born child of his family. His structure of family is nuclear but his

grandmother lived with them. He belonged to a middle socioeconomic status. His parents have

major fights nearly every day before the separation. After separation, mother with his both child

stays upper floor and father with his grandmother at ground floor. Till they have frequent fights

with child also. The home environment is not good. No authoritative figure present in the family.

Family have fights, disputers and quarrels most of the time.

Father. The client's father A.R is 38 years old and illiterate. He work at private institute. The

father has bad temperament and his relationship with his family is not up to the mark as he does

not get time to the family what they need especially regarding the children. No medical or

psychiatric history is reported.

Mother. The client's mother A.M is 34 years old. She has done intermediate and is housewife.

She is living a very busy routine with his family as she has to manage her daily tasks. The client

had very close relationship with his mother. There are no medical issues with mother except

blood pressure and no psychiatry history is reported.

Siblings. Client had only one siblings.

1st sibling. Client’s younger brother M.W is 6 years old. He is student of third grade. He is good

student and goes to school regularly. He had good personality. He was soft spoken. He also takes

part in extracurricular activities. The client enjoy healthy relations with his brother. He had no

psychotic and medical illness.

Educational history

At the age of 4 years old the client started kindergarten. He left school at age of 10 years

but after taking a gap of one year now he is going go to school again. He had firm relationships

with his teachers. The client was responsible and obedient student. It was also reported that he

make very few friends at school but had distant relationships with other class mates. He did

participate in curricular and extracurricular activities. His class performance was excellent. He

had no complaints from school about misbehaving with the teachers and fights with the seniors.

Premorbid Personality
 According to the clients mother he was little bit sensitive about his parent’s relationship

and studies before his illness but was not that much. He make friends easily but he had very

limited friend circle. His mother also reported that client enjoyed video games and played with

his younger brother but now as he becoming elder he wants to make friends and play with them

but due to restricted patterns of his home, he did not do this. He is friendly with his siblings and

love and care for them. Client used to do all work by his self and took good care of his younger

brother. Client was not stubborn and it was easy to convince him. Client was not demanding as a

child. Self-care of the client was appropriate before the illness. The mood of the client usually

remains euthymic, as he had a jolly nature and the client had adequate stress coping.

Psychological Assessment

Clinical Assessment was done to evaluate the information about the client’s family

background, other relationships, the onset of the problem and her present complaints. The patient

was presented with the complaints of grandiosity, more talkative than usual, pressure speech,

flight of ideas, distractibility, and goal directed activity for school and sexually, incoherent

speech, decreased need for sleep, excessive involvement in self-harm and suicidal ideation. For

proper and valid understanding of patient’s illness therapist has done informal and formal

assessment.

The assessment was done on two levels informal and formal

• Informal Assessment

• Formal Assessment

Informal Assessment
  Clinical Interview

 Subjective Rating Scale

 Mental state examination

 Dysfunctional Thought Record

Clinical Interview. Interview was conducted to obtain detailed information i.e. presenting

complaints, history of present illness, family history, personal history, educational history, sexual

history and premorbid personality of client. The client interview is foundation to psychological

or mental health treatment. It involves a professional relationship between a mental health

provider and a patient or client and is used across all major mental health treatment disciplines.

Although defined differently the clinical interview includes an informed consent process and has

its primary goals initiating of a therapeutic alliance, assessment or diagnostic collection, case

formulation, or implementation of a psychological intervention (Zeleke, Hood and Flanagann,

2015).

Clinical Interview was conducted to obtain detailed information i.e. presenting

complaints, history of present illness, family history, personal history, educational history and

premorbid personality of client.

Subjective Ratings of the client Symptoms

The client was asked to rate presenting complaints on the 10-point scale where

0=no problem

5=average

10=severe problem

Table 1.3

Symptoms Ratings

Irritability 09

Restlessness 09

Decreased need for sleep 08

Difficulty controlling worry 08

Visual hallucinations 04

Auditory hallucinations 04

Mental Status examination

Mental State Examination is a structured assessment of patient’s behavioral and cognitive

functioning. It includes description of person’s general appearance, speech, thought perceptions,

memory and insight about his or her illness. (Folstein, 1983).

 The client was a male with the age of 11 years. Client appeared to be child of tall height

and built. He was properly well-dressed. He was wearing clean and tidy clothes. He was not bit

comfortably sitting on the chair. The client was not hyperactive and not sitting in the same

posture, level of activity of the client was normal. His speech was clear and easily

understandable. Rate and volume of the client’s speech was low. Client was not defensive and

he openly tells about his problematic issues and circumstances He did maintained eye contact

properly throughout the interview. His orientation about time, place and person was good. He

was very cooperative. The content speech of the client was also normal. The client mood was

sad, upset and there was hopelessness in the speech of client. Depersonalization and DE

realization was not present observed through his answers and behavior. His abstract thinking was

good. The client reported visual and auditory hallucinations. His memory was intact. The client

had insight about his illness.

Dysfunctional Thought Recording

It is one of the most useful procedures of identifying and changing automatic thoughts.

This technique is first presented in relatively simple two or three column versions in the early

stages of therapy. Relatively, they can record events, thoughts, and emotions in the three

columns (Alford & Beck, 1997).

The functional analysis of DTR shows the intensity of problematic thoughts to be 80-90

percent. It is also depicted that patients symptom triggered when he thought about his mother

health and when his father and grandmother abuse him. He became irritated very easily. His

feelings include irritability and hopelessness. His behaviors include loss of comforts in daily life

accomplishments, restlessness and aggression.

Formal Assessment

 SDQ (Strength and Difficulties Questionnaire)

 BAI (Beck Anxiety Inventory)

 SCARED (Screening for Child Anxiety Related Disorder)

Formal Assessment

Formal assessment was done using SDQ, SCARED, BAI and HTP.

Strengths and Difficulties Questionnaire (SDQ)

It was developed by well-known person Robert N. Goodman in 2001. It is basically used

to measure the emotional and behavioral problems of children and young people. The 25 items in

the SDQ comprise 5 scales of 5 items each. The scales include emotional symptoms subscale,

conduct problems subscale, hyperactivity/inattention subscale, peer relationships problem

subscale and pro-social behavior subscale. The parent and teacher SDQ can be completed by the

parent or teacher of aged between 2 and 17 years old (Goodman, 2001).

Test Administration. SDQ (Goodman, 2001) was administered on the patient’s mother in

Monday, 6 and 2021 in a well-lit and ventilated room of the hospital. The room was peaceful and

noise free and there was not any distraction. It was not crowded and patient’s mother was seated

on a comfortable chair with a desk in front of it, placed on one side of the room. Instructions

were given to patient’s mother according to the manual. It took her almost 15 minutes to

complete the test.

Quantitative analysis. The quantitative analysis was shown in the table below.

Table 1.4
Table illustrating the raw score, range and remarks of patient on sub-scales of Strengths and

Difficulties Questionnaire (SDQ).

Sub-Scale Raw Score Range Remarks

Total Deviance score 20 17-40 Abnormal

Emotional symptoms score 5 5-10 Abnormal

Conduct Problems score 2 4-10 Normal

Hyperactivity score 9 7-10 Abnormal

Peer problems score 4 4-10 Abnormal

Pro-social behavior score 8 0-4 Abnormal

Qualitative analysis. The SDQ was able to assess the difficulties of patient. The result of this

questionnaire suggest that not only the total score, but most of the scores on other scales were

higher except conduct problems which were in adequate and normal range which reflects the

very much above average abnormality. The patient had abnormal emotional and behavioral

problems.

Conclusion. The results on Strengths and Difficulties questionnaire shows that M.A had

abnormal emotional and behavioral problems. The total deviance score shows that patient was

facing difficulties and problems in his life.

Beck Anxiety Inventory (BAI)

The BAI is a rating scale used to evaluate the severity of anxiety symptoms. The BAI (Beck,

Epstein, Brown, & Steer, 1988) is a self-report questionnaire measuring 21 common somatic and

cognitive symptoms of anxiety. he items reflect symptoms of anxiety, including: numbness or

tingling, feeling hot, wobbliness in legs, ability to relax, fear of the worst happening, dizziness
or lightheadedness, pounding or racing heart, unsteadiness, feeling terrified, feeling nervous,

feeling of choking, hands trembling, feeling shaky, fear of losing control, difficulty breathing,

fear of dying, feeling scared, indigestion or abdominal discomfort, faintness, face flushing, and

sweating. Each item allows the patient four choices from no symptom to severe symptom. For

each item, the patient is asked to report how he or she has felt during the past week. The items

are scored as 0, 1, 2, or 3.

Test Administration. BAI was administered on the patient’s on Monday, 6 and 2021 in a well-

lit and ventilated room of the hospital. The room was peaceful and noise free and there was not

any distraction. It was not crowded and patient was seated on a comfortable chair with a desk in

front of it, placed on one side of the room. Instructions were given to patient according to the

manual. It took patient about 30 minutes to complete the test.

Quantitative analysis. The quantitative analysis was shown in the table below.

Table 1.5

Table illustrating the raw score, range and remarks of patient on Beck Anxiety Inventory (BAI).

Raw Score Classification Level of Anxiety

37 36- and above potentially concerning levels of anxiety

Qualitative analysis. Client score on beck anxiety is 37 which indicate a severe level of anxiety.

Severe anxiety is intensely debilitating, and symptoms of severe anxiety meet key diagnostic

criteria for clinically-significant anxiety disorder. Client had severe anxiety typically score

higher on scales of distress and lower on functioning. Symptoms of severe anxiety are frequent
and persistent and may include increased heart rate, feelings of panic and social withdrawal.

These symptoms can result in loss of work and increased health care costs.

Conclusion. The results on Beck Anxiety Inventory (BAI) shows that M.A had severe level of

anxiety. The total deviance score shows that patient was facing increased heart rate, feelings of

panic and social withdrawal issues.

Screen for Child Anxiety Related Disorders (SCARED)

The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a measure widely used

to assess childhood anxiety based on parent and child report. The SCARED is intended for

youth, 9–18 years old, and their parents to complete in about 25 minutes. It can discriminate

between depression and anxiety, as well as among distinct anxiety disorders. Runyon, Chesnutt

and Burley (2018).

Test Administration. SCARED was administered on the patient’s and then on his mother on

Wednesday, 8 and 2021 in a well-lit and ventilated room of the hospital. The room was peaceful

and noise free and there was not any distraction. It was not crowded and patient was seated on a

comfortable chair with a desk in front of it, placed on one side of the room. Instructions were

given to patient and to his mother according to the manual. It took patient about 30 minutes to

complete the test.

Quantitative analysis. The quantitative analysis was shown in the table below.

Table 1.6

Table illustrating the raw score, range and remarks of patient on Screen for Child Anxiety

Related Disorders (SCARED).

Subscale Score Range Remarks

 Total score 46 > 25 Presence of an Anxiety Disorder.

Panic Disorder or Significant Somatic Symptoms 06 >7 Absence

Generalized Anxiety Disorder 14 >09 Presence

Separation Anxiety Disorder 12 >05 Presence

Social Anxiety Disorder 06 >08 Presence

Significant School Avoidance 04 >03 Presence

Qualitative analysis. The result showed that client total score indicates the presence of anxiety

disorder. According to the manual if scores are greater than 25 then the therapist had to see its

domains and as the domain shown the presence of Generalized Anxiety Disorder, Separation

Anxiety Disorder Social Anxiety Disorder, and Significant School Avoidance. Only the panic

disorder and significant Somatic Symptoms are absent in the client.

Conclusion. Client had relatively Generalized Anxiety disorder.

Diagnosis

The client was given 300.02 (F41.1), Generalized Anxiety Disorder.

Case conceptualization

Biological Dimension

Genetic influence: Family history of anxiety

(father)
 Psychological Dimension
Socio cultural Dimension
Anxiety evoking stimuli:
Stressful living conditions:
Generalized 1. Whenever went to that specific
1. Parents’ separation, room,
Anxiety Disorder
2. Living without with father, 2. when mother became ill,
3. Mother’s illness. (GAD) 3. When clients father and
grandmother abuses him.
Discrimination: Avoided by
grandmother from playing with
Use worrying as coping and
cousins and also outside.
worry about worrying

Social Dimension

Lack of social network: restrictions from

playing with cousins and outside the home.

Separation/Loss: parents live separately

Anxious parents: father is anxious,

hyperactive and abusive

Peer conflicts: no friend

Bio Psycho Social model of Anxiety disorder

Case formulation
 The client was 11 years old male belonged to the middle socio economic status.

He was admitted as an indoor patient at hospital with the complaints of excessive anxiety

and worry, difficulty controlling worry, restlessness, fatigue, irritable, decrease

concentration, sleep issues, sweating, distress and irregular heartbeat. The client was

diagnosed with anxiety disorder, according to Diagnostic and Statistical Manual of

Mental Disorder -5 (DSM-5).

Traditional psychological views of anxiety have been based on psychoanalytic

and learning theories. Although there are obvious differences between these points of

view, both theories treat anxiety as a signal of some expected negative event. Cognitive

perspectives on anxiety disorders emphasize the way in which people interpret

information from their environment (Roth, Wilhelm, & Pettit, 2005). Maladaptive

emotions such as chronic, generalized anxiety are presumably products of self-defeating

cognitive schemas. Some people make themselves unnecessarily anxious by interpreting

events in a negative fashion. In the present case client also interpret every event in an

exaggerated manner, because of some bad events that happen in his life he now

apprehend everyday events in a manner that something bad is going to be happen.

Borkovec and colleagues focus on the main symptom of anxiety disorder which is

worry in their cognitive model (Borkovec & Newman, 1998). Worry would seem so

unpleasant that one might ask why anyone would worry a lot. Borkovec and colleagues

have marshaled evidence that worry is actually reinforcing because it distracts people

from more powerful negative emotions and images. The key to understanding this

argument is to realize that worry does not involve powerful visual images and does not

produce the physiological changes that usually accompany emotion. Indeed, worrying
actually decreases psychophysiological signs of arousal (Freeston, Dugas, & Ladoceur,

1996) such as client is trying to avoid all the stressors such as illness of his mother and

father. According to cognitive theory, our dysfunctional thoughts lead to extreme

emotions. These extreme emotions in turn, lead to maladaptive behaviors. According to

cognitive theory, when cognitive distortions and core beliefs are modified, behavioral

change naturally follows. Client also over think about all the event and interpret them in a

wrong manner thus resulting in increased emotions and anxious behavior

Psychoanalytic theories conceptualize anxiety as arising from an unsuccessful

defense against anxiety-provoking impulses. What was previously a mild signal anxiety

becomes an overwhelming feeling of apprehensions. According to Freud's early

formulation, pathologic anxiety occurs when unacceptable libidinal thoughts, impulses,

memories, and desire break through into consciousness. The psychic energy attached to

these previously repressed components then appears in a disguised form. In this particular

case client is elder from the siblings and knows responsibilities and was not able to

express his feelings and tensions so he manifested all of these frustrations in the form of

anxiety regarding everything.

Predisposing Protective
Factors Factors

Mother admitted in Mother support

 Client conscious

Perpetuating
Factors
Precipitating
Factors Disturbed home
environment.
Separation of
client’s parents Abusive Father

Diagnosis

Generalized Anxiety Disorder

Therapeutic Recommendations

 Relaxation Exercise
 Dysfunctional Thought
Record
 Activity Scheduling
 Cost Benefit Analysis
 Instillation of Hope
 Guided Imagery
 Positive Reinforcement
 Assessment

 Clinical interview
 Behavioral observation
 Symptom checklist
 Dysfunctional Thought
Record (DTR)
 Strength and difficulty
Questionnaire (SDQ)
 Screen for Child Anxiety
Related Disorders
(SCARED)
 Beck Anxiety Inventory
(BAI)

Management plan
The management plan of the client was devised on eclectic approach, combining interventions of

different therapies.

Short term goals

 Try to build a rapport.

 Catharsis or emotional ventilation of client was done in order to relieve their emotions

and make them understand about their issues in a better way.

 Psycho education was provided regarding illness, its risk factors, cause, and prevention,

course of treatment and role of client.

 Compliance regarding treatment should be ensured, and client is encouraged to take

medicines on time and follow other instructions.

 Information about sleep hygiene is provided with other simples techniques to improve

sleep of client.

 Relaxation training was provided so that client can stay relaxed and calm down in case of

stress.

 Counseling was done.

 Guided imagery was done to make client relax and imagine good aspects of life.

 Anger management technique was taught as client was hyper.

 Behavior activation was done regarding self-care, intake of food and water

 Emotion thought record was provided to make client realize about their emotions and

their role in client’s behavior

 Double standard dispute was done to make client realize how they act if someone else is

behaving in similar manner

  Information about sleep hygiene is provided with other simples techniques to improve

sleep of client.

 EFT technique was used to help client release emotion.

Long term goals

 Activity scheduling was done, chart was made with the concern of client to use all the

time and not waste it by sitting idle.

 Stress coping techniques was taught to help client face any stressful event in a better way

 Thought distraction techniques were used to distract thought of client from main

symptoms.

 Engage the client in occupational therapy in order to utilize their time in effective way

and help them returning to normal life.

 Ensure the compliance of a client.

Therapeutic sessions

Session # 1
Session goals

 Introduction

 Confidentiality

 Rapport building

Session: In first session client was introduced to the therapist. Complete Bio data was taken from

the client. Starting from the bio data name, age, siblings, birth order, and education was asked to

the client. Same possessions were also told by the mother just to check the truthfulness of the

client and to ensure that how much client is avoidant to tell his personals. Rapport building with

the client was done. Although it takes a lot of time to done. Comfortable relationship was made

through providing trust and confidence to the client. In the present case, rapport was built by

asking the patient’s name, how the patient is doing, actively listening to the patient, showing an

attitude of acceptance, and respect, by empathizing with his problem and distress and ensuring

him the confidentiality of information and by showing motivation to help the patient in bringing

improvement in his problem. The patient will be asked about how his problem affected his

functioning in different areas of life and what brings him today. As the patient, did not have

therapy before so he will be made convinced about psychotherapy by building trust and

reassurance regarding therapy and improvement in his condition. This will help the client to open

up and disclose his feelings. Through the building of strong trust and rapport with the client the

client became very friendly and he was not hesitant to talk and to tell his personal problems and

the difficulties he is facing now a days. In initial of the first sessions, the client was a little bit

reserved but later on he become expressive. Client was told about the confidentiality and he was

asked that all of his information will be kept secret and nor his personal stuff neither his private
information will be revealed to feel comfortable talking about and need of a safe place to talk

about anything they'd like, without fear of that information leaving the room. The issue of

confidentiality was discussed with the mother involved when treating a child client at the

beginning of the therapy. Private agreement with the mother was also taken to withhold their

request for information, so that the child may have a greater sense of privacy in the therapeutic

relationship. The parents will also be informed that the confidentiality will be opened when the

life or safety of the child is endangered. Patients was going over traumatic life fluctuations and

the emotional breaker so he was unwilling to share his most private feelings with a stranger

unless he know that his secrets are safe. That’s why confidentiality is so important to make

therapy effective.

Session # 2

Session goals
  Rapport building

 History taking

 Mental Status examination

 Subjective rating of the presenting complaints

Session. In the second session firstly the client’s mother was asked about the clients sleep,

appetite and mood. She told the therapist that his sleep is very poor and disturbed. He did not

take his regular meals instead of it he take a little bit of junk food to satisfy his appetite. Clients

mood was low as told by the mother and also was observed during the session. Major focus was

again on rapport building in an attempt to gain detail history of the problem. The purpose of

taken history from the client’s mother was to insure the onset, present problem and factors

regarding the illness. Client’s mother and client his self was cooperative and they discussed the

detailed history and answer every single question asked by the therapist. History was taken from

the client and his mother including the history of present illness, birth history, and educational

history. Major findings were brought out from the history and formulated by the therapist. The

precipitating factors, perpetuating factors, predisposing factors and protective factors were

formulated from the history to formularize in the manner. Informal assessment was also done

through the procedure of Mental State Examination which is a structured assessment of patient’s

behavioral and cognitive functioning and it includes description of person’s general appearance,

speech, thought and perceptions, level of consciousness and attentiveness, mood and affect,

cognitive abilities, memory and insight about his or her illness. The client was a male with the

age of 11 years. Client appeared to be child of tall height and built and weight according to his

age. He was properly well-dressed. He was wearing clean and tidy clothes. His hygiene was

good. He was not bit comfortably sitting on the chair. The client was not hyperactive and not
sitting in the same posture, level of activity of the client was normal. His speech was clear and

easily understandable. Rate and volume of the client’s speech was low. Client was not defensive

and he openly tells about his problematic issues and circumstances He did maintained eye

contact properly throughout the interview. His orientation about time, place and person was

good. He was very cooperative. The content of the speech of client was also normal and

understandable. He responded every aspect briefly and sometime precisely. His response was

relevant to the question. The client mood was sad, upset and there was hopelessness in the

speech of client. Clients thought process was intellectual. Depersonalization and DE realization

was not present observed through his answers and behavior. Client’s attention span was good.

His abstract thinking was good. The client reported no obsessions. The client reported visual and

auditory hallucinations. Client’s judgment was adequate. He had no suicidal and homicidal

ideations. His short term and long term memory was intact. The client had insight about his

illness. To check the understanding of client’s problems and severity visual analogue scale was

used. As Visual analogue scales (VAS) is psychometric measuring instrument designed to

document the characteristics of disease-related symptom severity in individual clients.

Subjective rating scales are widely used in almost every aspect of practice for the assessment

of workload, fatigue, usability, annoyance and comfort. The history of the symptoms tells the

therapist about the behavior of the condition in the past and may therefore assist in goal setting

and prediction of prognosis. The client was asked to rate presenting complaints on the 10-point

scale where

0=no problem, 5=average, 10=severe problem.

Subjective Ratings of the client Symptoms (pre assessment)

Presenting Complaints Ratings

Irritability 09

Restlessness 09

Decreased need for sleep 08

Difficulty controlling worry 08

Visual hallucinations 04

Auditory hallucinations 04

Session # 3
Session goals

 Review and feedback of previous session

 Strength and Difficulties Questionnaire

 Dysfunctional thought record

 Homework

Session. Overview of previous session was taken from the client and his mother. As told by the

client’s mother she was satisfied and overwhelmed with the therapist. Client was also asked

about the session. Client told the therapist about the points which he had to talk more and

showed his satisfaction regarding the confidentiality of his provided information. As told by the

mother clients mood was low, his sleep was disturbed and he had poor appetite. She also told the

therapist that his child is facing the restlessness issues regarding following the daily routine and

he became irritable very easily. Client’s personality before illness was discussed briefly which

open up major doors for the therapy and to have good prognosis. For identifying and changing

automatic thoughts Dysfunctional Thought Record chart was given to the patient. Firstly the

rationale of DTR was told to the client’s mother. Secondly child was given blank paper and five

different columns were made with the help of pencil and scale. Then the child was asked to how

to write in theses separate five different blocks which includes event, thought, emotion, intensity,

what he uses for distraction and after using distraction stimuli what changes are brought in him

and what should he had to put in them. SDQ was administered on the patient which includes

emotional symptoms subscale, conduct problems subscale, hyperactivity/inattention subscale,

peer relationships problem subscale and pro-social behavior subscale. Instructions were given to

patient’s mother according to the manual. It took her almost 15 minutes to complete the test.

Homework. The client was asked to fill and properly write down the dysfunctional thought

record chart for the whole week when ever certain event occur.
 Session # 4

Session goals

 Review of previous session

 Beck Anxiety Inventory

 House Tree Person test

 Screen for Child Related Anxiety Disorder

Session. Overview of session was taken from the client and his mother. Client’s behavior at

home and how much he follow the instructions properly was discussed by his mother.

Homework given to the client was checked. Client fill the DTR Performa which highlights the

problem, its nature and intensity. Formal assessment of client was done during the session.

Client’s mood was up to the mark, his sleep was proper but his appetite was still disturbed. Beck

Anxiety Inventory was administered on the patient’s. Client’s mother was told by the therapist

that what the purpose of using BAI is. Instructions were given to patient according to the

manual. It took patient about 30 minutes to complete the test. The total deviance score shows

that patient was facing increased heart rate, feelings of panic and social withdrawal issues. HTP

was applied on the child. Firstly the rationale of HTP was briefly explained to the mother of the

client. During the first phase, the child was asked to draw the house, tree, and person and the

therapist asks questions about each picture. The interpretation of these drawings is used to create

a picture of the person's cognitive, emotional, and social functioning. Screen for Child Related

Anxiety Disorder (SCARED) was administered on the patient’s. The result showed that client
total score indicates the presence of anxiety disorder. Instructions were given to patient and to

his mother according to the manual. It took patient about 30 minutes to complete the test.

Session # 5

Session goals

 Review and feedback of previous session

 Psych educate

 Deep breathing

 Homework (Deep Breathing)

Session. Overview of previous session was taken from the client and his mother. As told by the

client’s mother she was satisfied and overwhelmed with the therapist. Client was also asked

about the session. Client told the therapist about the points which he had to talk more and

showed his satisfaction regarding the confidentiality of his provided information. As told by the

mother clients mood was low, his sleep was disturbed and he had poor appetite. She also told the

therapist that his child is facing the restlessness issues regarding following the daily routine and

he became irritable very easily. Client’s personality before illness was discussed briefly which

open up major doors for the therapy and to have good prognosis. Psycho-education was provided

to the mother. She was informed about disorder's symptomatology, peculiar outlines, reasons and

etiological factors. Psych education is an intervention with systematic, structured, and didactic

knowledge transfer for an illness and its treatment to patient and their families and integrating

emotional and motivational aspects to enable patients to cope with the illness and to improve its

treatment adherence and efficacy. It also includes providing information about mental health
conditions to the family of sufferer. She was explained about the therapy process and the

importance of management strategies. She was provided with emotional support and told that

client's problem is manageable, and with her cooperation and effort client's condition could get

better. Importance of homework exercises and mother's role in the therapy was highlighted. The

mother was asked to follow the instructions. Concerns of the mother regarding diagnosis and

management procedure were addressed. Relaxation training was provided to patient. Both the

client and informant (mother) was told that relaxation technique is a method, process, procedure

and activity that helps a person to relax, to attain a state of increased calmness or otherwise

reduce levels of anxiety, stress or anger. Relaxation techniques are often employed as one

element of a wider stress management program and decrease muscle tension, lower blood

pressure and slow heart and breathing rates, among other health benefits. Relaxation techniques

can be helpful tools for patient for coping with stress and the anxiety promoting long term health

by slowing down the body and quieting the mind. The purpose of using such technique by the

therapist was just too generally entail refocusing attention, increasing body awareness, and

exercises (such as meditation) to connect the body and mind together. Client was told that if he

practice it daily, then these practices can lead to a healthier perspective on stressful

circumstances on him. Patient can be helped to cope with the stress and anxiety in his life by

using relaxation. A simple, popular method to promote relaxation involves deep breathing. In

this technique diaphragm is used, one slowly breath in, held ones breath for a moment, slowly

breath out, wait a few seconds, and then breath in again. The cycle is repeated for two minutes

by the patient. These techniques can play an important role in the recovery of the patient, by

making client less vulnerable to the stressors in his life.

Homework. The patient was asked to model this behavior and to practice deep breathing at

home. Chart for whole week was made on a blank paper by directing on the patient’s needs that

when he had to do the Progressive Muscle Relaxation training.

Session # 6

Session goals

 Review of previous session

 Progressive Muscle Relaxation training

 Counselling and motivation to the mother

 Homework (PMR chart)

Session. Overview of session was taken from the client and his mother. Client’s behavior at

home and how much he follow the instructions properly was discussed by his mother. Client’s

mood was up to the mark, his sleep was proper but his appetite was still disturbed. Progressive

Muscle Relaxation training was provided to the client. It is an effective technique to release the

tension of body due to psychological disorder. It contains 16 different muscles of body. These

muscles were tense and then relax slowly. Its goal is to enhance the bodily movement and release

tension. It was taught to the client on steps and the steps of the Progressive muscle relaxation are

as following. Firstly the therapist will explain the purpose of PMR to the patient. Secondly the

therapist will explain each and every single step of PMR to patient and ask the patient to model

this behavior. In the first step the child was asked to get comfortable by just sitting up in a chair

in calm state of mind. It was make sure that client and therapist was in a place that's free of

distraction. Client was asked to close his eyes if that feels best for him. Then the client was asked
to breathe and Inhale deeply through his nose, feeling his abdomen rise as it fill his diaphragm

with air. Then slowly exhale from the mouth, drawing navel toward the spine and repeat three to

five times.in the third step the client was asked to tighten and release his muscles, starting with

his feet and then clench toes and pressing his heels toward the ground. Squeeze tightly for a few

breaths and then release. Now flex the feet in, pointing toes up towards the head. Hold for a few

seconds and then release. Client was asked to continue to work his way up to his body,

tightening and releasing each muscle group. Work his way up in this order: legs, gluteus,

abdomen, back, hands, arms, shoulders, neck, and face. Try to tighten each muscle group for a

few breaths and then slowly release. Repeat any areas that feel especially stiff. The take a few

more deep breaths, noting how much more calm and relaxed you feel. After modeling, patient

will start PMR independently with only instructions of therapist. Then the patient will be asked

about his experience after doing exercise and post rating of problem will be noted as well.

Mother was counseled that from tending to the daily needs of the child, parents are also

responsible for helping their children develop social skills, life skills and appropriate behavior.

Continuous counselling of the parents is crucial as they learn to cope with their personal

inadequacies and their feelings of guilt and stress. She was motivated to work hard and to give

time to their child so that chances of betterment in clients condition increases. Therapist provide

counseling the mother how to treat a child at home. It is important to ask the mother about the

child’s problems and listen to what she is already doing for the child, this will include praising

her for the things that she is doing well and advising her on things she can do to improve the care

of her child at home. Mother was told that there are three basic teaching steps she should take

when teaching her child at home. These are: give information, show an example and let her

practice. Letting a mother practice is the most important part of teaching a task because the
mother is more likely to remember something that she has practiced than something that she has

heard.

Homework. Importance of homework exercises was told to his mother. The mother was asked to

follow the instructions and counselling was provided to her. Regarding the homework schedule.

Each and every single step of PMR to patient was taught to the patient. The patient was asked to

model this behavior and to practice PMR at home. Chart for whole week was made on a blank

paper by directing on the patient’s needs that when he had to do the Progressive Muscle

Relaxation training.
 Session # 7

Session goals

 Review of previous session

 Activity Scheduling Chart

 Sleep hygiene tips

 Homework ( Relaxation exercise, sleep hygiene tips and Activity chart)

Session. Overview of session was taken from the client and his mother. Patient will be asked

about his experience after doing exercise and post rating of problem will be noted as well.

Homework given to the client in the previous session was checked. Client’s mother told the

therapist that patient’s mood, sleep and appetite was normal. Activity scheduling is a process of

restoring the level, quality and range of activities and interactions by carefully scheduling those

activities which demonstrate reinforcement potential for the patient. It is an effective tool to

engage the patient in the activities which were part of his routine. It works as a timetable for the

patients. Its present goal is to engage patient in the activities which were pleasurable for him

before illness to combat his irritability and laziness. Activity chart was made by firstly

explaining the purpose of daily routine chart that why a therapist formularized it for the patient.

The activity chart was based on the need of child physical well-being, education, hobbies, social

relations, emotional health, meaningful daytime activity, and spirituality. Secondly certain steps

were made in order to simplify it which includes the following steps:

• The rationale of activity scheduling will be explained to patient and patient’s mother.
• An activity chart for whole week will be made on a blank paper by focusing on the patient’s

personality.

• This chart will be provided to patient and explained thoroughly.

• After one week, therapist will took this chart to see the results and make changes according to

progress.

Good sleep habits sometimes referred to as “sleep hygiene” can help child get a good night’s

sleep. Therapist provided Sleep hygiene tips to the child that can improve his sleep health.

 The actual routine of child can be specific, but it should last around 20 minutes and

consist of three to four quiet, soothing activities such as brushing teeth, a warm bath, and

reading. Bedtime routines provide children with a sense of familiarity and comfort, Go to

bed at the same time each night and get up at the same time each morning, including on

the weekends. Bedtimes are most useful when they’re consistent, so try to keep the same

bedtime on weekends as on school nights.

 Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature.

 Remove electronic devices, such as TVs, computers, and smart phones, from the

bedroom

 Avoid large meals and tea before bedtime

 Get some exercise. Being physically active during the day can help child fall asleep more

easily at night. These often consist of simple breathing techniques, body awareness, or

guided imagery.

Homework. Child was asked by the therapist to follow the activity chart for one week and major

changes were made if needed but beside the formation of activity chart the therapist made
compulsory for the patient to practiced regularly relaxation techniques such as progressive

muscle relaxation, and deep breathing can reduce anxiety symptoms and increase feelings of

relaxation and emotional well-being. Patient was told to exercise regularly. Exercise is a natural

stress buster and anxiety reliever. Childs mother was asked by the therapist to make sure that the

patient follow the sleep hygiene tips for proper sleep.

Session # 8

Session goals

 Review of previous session

 Mindfulness

 Problem-Solving Therapy

 Homework assignment

Session. Overview of previous session was taken from the client and his mother. Child was

asked about the homework task. Patient mother told the therapist that his child had followed the

routine and she also told the affectivity of activity chart due to which his routine had made and

the irritability and restlessness along with the increase in heart rate and fear had become less

because he remain busy in performing the daily tasks due to which his mood remain stable, his

appetite had normal now and he did not disturbed at night during sleep. Practicing mindfulness

involves breathing methods, guided imagery, and other practices to relax the body and mind and

help reduce stress. Mindfulness has also clearly been shown to be effective in improving

mental health,wellbeing, reduce worries, anxiety, distress, reactivity and bad behavior,
improve sleep, self-esteem, and bring about greater calmness, relaxation, and awareness.

Mindfulness teaches the client how to respond to stress with awareness of what is happening in

the present moment, rather than simply acting instinctively, unaware of what emotions or

motives may be driving that decision. Firstly therapist ask the child to counting his breath.

Secondly he should sit quietly with the closeness of eyes closed or half open, clear the mind, and

count child own breath without trying to change or control it. Thirdly lengthen the process of

exhale. Count as he breathe. Fourthly breathe through alternate nostrils and make it a habit.

Hopeful view of managing, and innovatively improve an accomplishment proposal geared to

diminish mental suffering and heighten welfare. Problem solving therapy is a cognitive

behavioral intervention geared to improve an individual’s ability to cope with stressful life

experiences. The underlying assumption of this approach is that symptoms of psycho-pathology

can often be understood as the negative consequences of ineffective or maladaptive coping. The

steps of problem solving that were taught to the client included the following:

 Defining the problem in clear specific term

After the problem has been identified, it is important to fully define the problem so that it can be

solved. Child was firstly asked that what are the problems that he is currently trying to solve in

his life? Therapist told the child that problem solving does not usually begin with a clear

statement of the problem, rather, most problems must be identified in the environment; and then

they must be defined and represented mentally. Well-defined problems have specific goals,

clearly defined solutions, and clear expected solutions.

 Brainstorming a number of possible solutions

To define the problem, there are a few important steps. First, brainstorm and talk through what

the underlying problem is. You may know this easily, or it may be more complicated. Chart

about all possible angles, focusing more on the true problem and not getting caught up in

symptoms.

 Examining the pros and cons of each brainstormed solution.

Homework. Child was asked by the therapist to repeat mindfulness in the morning with deep

breathing and walk so his concentration increases and he feel less anxious.
 Session # 9

Session goals

 Review of previous session

 Problem-Solving Therapy

 Catharsis

 Homework assignment

Session. Overview of the previous session was taken from the client and his mother. Child was

asked by the therapist about the completion of the homework. Child said that he do mindfulness

in the morning with deep breathing and also go out for a walk.

Problem solving therapy is aimed to help the patient adopt a realistically optimistic view of

coping, and creatively develop an action plan geared to reduce psychological distress and

enhance well-being. This is also used to make patient think of realistic and appropriate ways of

dealing with a problem. Choosing the best hypothesized solution. The child should be asked to

choose the solution by his self which is appropriate then other. E.g. child did not focus on daily

homework from school for hours so he suggest that he will do homework but with the breaks.

 Implementing the solution after some planning, preparation and practice. After going

home the child work in a proper manner by working in peaceful manner and after 45

minutes take a gap of 15 minutes and in this particular time he ate snacks. After this, he

came back to work so he feel relaxed and did not felt tired.
Catharsis was provided by the therapist to the child’s mother because she was very much anxious

and worried about the health of child and the separation from his husband so catharsis was

provided to her. According to the American Psychological Association, catharsis in psychology

refers to "the release of formerly repressed consequences connected to worrying activities that

arise while these events are introduced returned into focus and re-experienced. It is the first step

in helping clients apprehend themselves so they can make higher decisions to consider the

religious ritual of confession or the force we feel from childhood to position our secret mind

down in diaries. She was told to make a diary of her own. She was told that by the therapist that

when you release the emotions that you were holding onto, you will bring them into awareness.

This helps bring about insight about you, in addition to simply getting things off our chests. It

gives you a sense of control over how you feel, and sometimes it feels as if a burden has been

lifted. This creates the positive experience that everyone associates the word catharsis with and

stays true to its traditional meaning cleansing, purging, or purification. She was asked that it is

the emotional states like disgrace or guilt are often born or bolstered by our terrible concept

styles, so therapist encourage her to take a cathartic approach toward processing her mind, too.

She was encouraged by the therapist most effectively to talk approximately past lessons and

emotions. The purpose of this remedy was to move deeper than the character normally does in

their normal existence, so that she can enjoy catharsis with the foundation troubles in his present

problems. Emotional repression was realized and understood with the help of a therapist, and

help was providing regarding to process the feelings that she is having.
Homework. Child was asked by the therapist to follow the activity chart by making different

changes and made compulsory for the affected person to practiced regularly rest strategies such

as mindfulness, meditation, progressive muscle rest, and deep respiratory can reduce tension

signs and symptoms and boom feelings of relaxation and emotional well-being. Patient was

instructed to exercising regularly and to follow an activity scheduling chart.

Session # 10

Session goals

 Review of previous session

 Instillation of hope

 Cost–benefit analysis

 Homework assignment

Session. Overview of previous session was taken from the client and his mother. Client’s mood,

appetite and sleep was normal. Mother reported that the child completed the homework at home

completely and he do follow his mother instruction properly. Instillation of hope technique was

used by the therapist to offer desire to the patron that restoration is reasonable. Firstly the

rationale of instillation of hope was told to the client that if it increases in therapy then it predicts

resilience and restoration from tension. It is a critical mechanism for therapists to repair in

sufferers to transport them forward closer to recovery. The instillation of hope creates a sense of

optimism. Child mother was told by the therapist that lack of desire mentioned that people

without wish have a long way poorer health consequences than people who do so she should

focus on child as well as her mental health to overcome stress and anxiety in the child. Because

desire is a component that relates to a people view of the destiny, its far inevitability associated
with effects of one’s lifestyles. The therapist told the patient and made him agreeing that strong

sense of believing in his self and to do the tasks properly, to believe that he can do everything

will leads towards the betterment and chances of healthy life would increase. Hope will increase

in therapy advancement and is a trait that expects resilience and restoration from tension issues.

Instillation of hope motivate the client to move them ahead towards healing. Yalom asserts that

the installation and maintenance of hope is essential in any psychotherapy. Not most effective is

desire required to keep the customer in remedy in order that other therapeutic factors may also

take impact. Yalom believes that an effective final results in psychotherapy is more likely when

the client and the therapist have similar expectations of the remedy. Yalom (2005) asserts that a

high expectation of assist earlier than the start of therapy is drastically correlated with an

advantageous therapy outcome. Faith inside the remedy mode itself is therapeutically powerful.

Client’s mother was also provided a sense of hope through talk. It takes almost 15 minutes to tell

her mother that to work with motivation with the child and to have stronger belief of betterment

would lead towards the betterment of child’s life and his anxiety issues would reduce. Therapist

provide mother instillation of hope in certain steps. She was told that:-

1. Stay away from impression that nothing is wrong

2. Consolation outfitted that it's genuine and there had been no regular explanation three. Give

models

4. Clarify roughly what oblivious mean for direct.

5. Consolation was typically provided by expressing shared regret for the loss of child’s mental

health and studies and highlighting the hope for positive events in the future.
6. Verbal support was given that provide signs and indications of improvement.

7. Give time to patient and yourself. Effects, circumstances and happenings need time to

transform and to be restored and recovered.

In cognitive behavioral therapy (CBT), cost benefit analysis approach has been designed to be

used in cognitive restructuring. Put extra truly, a value and advantage evaluation can be used to

assignment antique, bad styles of thinking, allowing them to be replaced by means of new, extra

adaptive mind. A cost-benefit analysis (CBA) is the manner used to measure the advantages of a

selection or taking movement minus the charges associated with taking that movement. It was

implemented on the patient to challenge his self-schemas and disturbed behavioral patterns.

Firstly the rationale of implementing this technique was given to the patient. Secondly

demonstration was given to him for the purpose of understanding in easier way. Thirdly paper

and pencil was given to him and then he was asked to make cost benefit analysis of if he will

listen to his mother instructions then who would be benefitted and what are the benefits of

listening his mother. Child make proper task through which his thoughts were challenged.

Homework. Child was asked by the therapist to follow the activity chart by making different

changes and made compulsory for the affected person to practiced regularly rest strategies such

as mindfulness, meditation, progressive muscle rest, and deep respiratory can reduce tension

signs and symptoms and boom feelings of relaxation and emotional well-being. Patient was

instructed to exercising regularly.

 Session # 11

Session goals

 Review of previous session

 Guidance

 Hierarchy for fear

Session. In this session firstly the client’s mother was asked about the clients sleep, appetite and

mood. She told the therapist that his sleep is proper now as well as he is focusing and following

sleep hygiene tips to sleep well. She also said that child take his regular meals to satisfy his

appetite and following the activity schedule properly. Clients mood was good as told by the

mother and was also observed during the session. Problematic events in the previous days were

discussed and motivation was provided to the client to fight from the fear from his self. Mother

was guided regarding her issues to the child. Therapist told different statements to guide Childs

mother which are mentioned below:-

1. Encouragement should be provided that she had worked hard for his child. She should

watch his child that what are certain situations that make her children most afraid, and

she will encourage his kid to not avoid the things they’re afraid of. Being a parent she

should look for situations and circumstances and experiences where client is going to

have to deal with his anxiety.

2. Help your child to face fears. The therapist ask how you can help your child practice at

home. Praise your child for efforts to cope with fears and worry.
 3. Help patient to talk about feelings. Listen, and let him know that you understand, love,

and accept them. A caring relationship with you helps your child build inner strengths.

4. Encourage your child to take small steps forward. Don't let your child give up or avoid

what they're afraid of. Help them take small positive steps forward.

5. The goal isn't to eliminate anxiety, but to help a child manage it. However the mother

learns an amazing deal which assists her in the upbringing of all her youngsters.

Fear arises with the risk of damage, either physical, emotional, or mental, actual or imagined.

While historically taken into consideration a “terrible” emotion, fear sincerely serves a crucial

role in maintaining us secure because it mobilizes us to cope with capability threat. Child was

instructed by way of the therapist that the fear hierarchy is a listing that you make of the triggers

that make you feel afraid or disturbing. After you write them down, you rank them from the only

that makes you sense least anxious or traumatic to the only that scares you the most. Patient

changed into advised by the help of the therapist to make a list. Make a listing of situations,

locations or items that he fear. Then secondly construct a Fear Ladder. Once you have got made

a listing, set up things from the least horrifying to the most horrifying. Thirdly facing fears

(exposure) beginning with the situation that reasons the least anxiety, again and again have

interaction in. Fourthly practice it to 3 instances. Through finishing the lower level objects first,

the child will be capable of develop confidence in finishing those obligations and can exercise

the usage of coping capabilities in less distressing environments and at the give up praise become

given for his courageous behavior.

Homework. It was based on what child learn during the session. Child was asked by the

therapist to overcome his fear at home by following certain steps of fear of hierarchy made

during the session. Mother was also instructed to not to help the child from facing the fear.

Session # 12

Session goals

 Review of previous session

 Positive reinforcement

 Self-help techniques

 Homework assignment

Session. Overview of previous session was taken from the client and his mother. Client’s mood,

appetite and sleep was normal. Mother reported that he attempted the homework at home

complete and she also strictly ask him to do his task. Positive reinforcement is the presentation of

a reward immediately following a desired behavior intended to make that behavior more likely to

occur in the future (Miltenberger, 2006). Continuous positive reinforcement was used by the

therapist during the sessions when the client acquired the behavior such as complete the

homework tasks, properly listen to the instructions of his mother, do not fight or quarrel at home,

do not waste time, play with the younger brother, do not do overthinking. Whenever the client

exhibited the target behavior, he was reinforced by giving him extra pocket money and stars.

Verbal reward, which is maximum a success when the remarks is true, specific, and right now

follows the exposure “Great task to a person individually!” in place of “Great job!”), so the child

is aware what brave conduct is recognize. This makes the conduct more likely to recur. However,
afterwards the therapist moved on to intermittent reinforcement to maintain the behavior. Self-

assist strategies had been taught and client became recommendation to apply these strategies

even after leaving health center to prevent relapse. Self-assist strategies involve some steps

together with keep away from isolation, slow breathing. When you're nerve-racking, your

respiratory turns into quicker and shallower prepare for progressive muscle relaxation, stay

inside the present second, healthy way of life, take small acts of bravery, challenge yourself-

communicate, plan worry time, get to realize your anxiety spend time with friends and circle of

relatives, eat a healthful temper-boosting food regimen, venture poor mind, ruin down

overwhelming tasks into small chunks, accept duty, have a regular sleep pattern, do things that

sell relaxation and deliver energy.

Homework. Child was instructed to do deep breathing, progressive muscle relaxation training,

to follow the activity chart. Mother was asked to follow the instructions to maintain child proper

routine.
 Session # 13

Session goals

 Review of all the previous sessions

 Post assessment of subjective rating of symptoms

 Relapse prevention

 Session termination

Session. Overview of all the previous sessions was taken from the client and his mother. Client’s

mood, appetite and sleep was normal. Client reported improvement in his symptoms.

Post assessment

Post assessment was done with the client to assess the improvement in symptoms intensity.

Subjective Ratings of the client Symptoms (Post assessment)

Pre Rating Post Rating

Irritability 09 04

Restlessness 09 04

Decreased need for sleep 08 03

Difficulty controlling worry 08 03

Visual hallucination 04 00

Auditory hallucination 04 00
Graph 1.1

Graphical Representation of the Outcome of the Management

Relapse Prevention

A relapse is a complete go back to all your antique approaches of wondering and

behaving when you are traumatic. People who have a relapse are generally doing the identical

matters that they did earlier than they discovered a few new strategies for managing anxiety.

Relapse prevention is visible as part of the method of self-discovery. It entails developing

"private techniques" to deal with symptoms and stressors and to keep health. When it comes to

preventing relapse, there are three big parts to self-management: identifying your warning signs,

taking action, and seeking outside help when it's needed. Child was told to make a time table for

yourself of what abilities you will work on every week. Follow a balanced lifestyle, identifying

and coping with high-risk situations this might encompass exposure, or practicing a few calm

respiratory and rest. Get buddies and family to help.

Termination Session

In the last session client was provided hopeful view of managing, and innovatively

improve an accomplishment proposal regarded to diminish mental suffering and heighten

welfare. As the client’s progress was favorable and he was working on his behavior. All the

skills and behaviors learned in the session were reviewed. His symptoms are getting better. So it

was decided to terminate the session as client was feeling relaxed and also motivated to follow

therapy techniques. After taking post rating of the symptoms and giving concluding remarks

therapist terminated the session.

References

Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring

clinical anxiety: Psychometric properties. Journal of Consulting and

Clinical Psychology, 56, 893-897.

Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999).

Psychometric properties of the Screen for Child Anxiety Related

Emotional Disorders (SCARED): a replication study. Journal of the

American Academy of Child and Adolescent Psychiatry, 38(10), 1230–6.

Behrens, B., Swetlitz, C., Pine, D. S., & Pagliaccio, D. (2019). The Screen for Child

Anxiety Related Emotional Disorders (SCARED): Informant Discrepancy,

Measurement Invariance, and Test-Retest Reliability. Child psychiatry

and human development, 50(3), 473–482. https://doi.org/10.1007/s10578-

018-0854-

Runyon K, Chesnut SR, Burley H (November 2018). "Screening for childhood anxiety: A

meta-analysis of the screen for child anxiety related emotional disorders". J Affect

Disorder. 240: 220–229

Clark, D. A. (2013). Cognitive restructuring. The Wiley handbook of cognitive

behavioral therapy, 1-22.

 Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau, N., Rhéaume, J., Letarte, H., &

Bujold, A. (1997). Cognitive—behavioral treatment of obsessive thoughts:

A controlled study. Journal of Consulting and Clinical Psychology,

65(3), 405– 413. https://doi.org/10.1037/0022-006X.65.3.405

Butler, Andrew & Chapman, Jason & Forman, Evan & Beck, Aaron. (2006). the

empirical status of cognitive-behavioral therapy: A review of meta-

analyses. Clinical psychology review. 26. 17-31. 10.1016/j.cpr.2005.07.003.