Case Summary

The client was 25 years old young man of normal height and thin built. His
education was matriculation. He discontinued studies because of increasing interest in
other activities. He used to sit much with his friends and started using cigarettes, and
later on alcohol. Meanwhile, client did many jobs in order to earn some money. He
worked as a sales man and also worked at a tea stall. He was also admitted to hospital
for his treatment for three months. After recovering he started his job, there he
became addicted once again as some of his fellow workers also used drugs. The client
then started using chars and this causes him a lot of health issues. Later on, he started
using heroin that also became the cause of his job problems. His family came to know
about his addiction at that time. His family took him to Akhtar Saeed Trust Hospital,
Lahore for treatment purpose. He was referred to clinical psychologist for initial
history, assessment and treatment. His behavioural observation and MSE was done.
His MSE revealed that his attention and concentration was normal, was maintaining
his hygiene. His appearance was consistent with his chronological age. His gait and
speech were appropriate. He had intact remote, recent memory. According to his
history, formal and informal assessment he was diagnosed with Opioid Withdrawal.
The therapeutic recommendations for the client included rapport building, deep
breathing, supportive psychotherapy, 16 muscle relaxation, medication adherence,
sleep hygiene, anger management, craving management, modification of thoughts,
problem solvin
Bio Data
Name MF
Age 25 years
Gender Male
Education Matriculation
Siblings 6 (4 sisters & 2 brothers)
Birth order 3rd
Marital Status Unmarried
Religion Islam
Occupation Sales man
Informant Mother
City Lahore

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Reason for Referral
The client came to the psychiatry department of Akhtar Saeed Trust Hospital,
Lahore with the complaints of restlessness, fatigue, diarrhea, irritability, aggression,
frustration, headache, and insomnia, and referred to the clinical psychologist for the
purpose of psychological assessment and treatment.

Presenting Complaints

‫دورانیہ‬ ‫علامات‬
۲ ‫ہفتے‬ ‫بے چینی رہتی ہے‬
۲ ‫ہفتے‬ ‫نیند نہیں آتی‬
۲ ‫ہفتے‬ ‫پتھوں میں درد ہوتا ہے‬
۲ ‫ہفتے‬ ‫تھکاوٹ رہتی ہے‬
۱ ‫مہینہ‬ ‫غسہ آتا ہے‬
۲ ‫ہفتے‬ ‫ہر وقت سر درد ہوتا ہے‬
۳ ‫ہفتے‬ ‫پیٹ میں درد ہوتا ہے‬
۲ ‫ہفتے‬ ‫مایوسی محسوس ہوتی ہے‬
Behavioural Observation
The client was 25 years old unmarried man of average height and built. He
was wearing trouser and shirt. His hair was not combed. He had a coordinated gait
and maintained a proper eye contact throughout the observation. His appearance was
persisted with his reported chronological age. He was well oriented to the time, place
and person. After giving some instructions the trainee clinical psychologist started to
administer the test. The client was very cooperative, he did not take any break and
calmly answer all the statements.
History of Present Illness
The client used to have different drugs that are cigarette, alcohol and chars in the
company of his friends in 2013. He became addicted with the passage of time and his
social and occupational functioning reduced. He was a sales man at cloth shop but due
to the adverse effect of drugs he became unable to continue his job properly. He had
symptoms like diarrhea, irritability, fatigue and insomnia.

84
 According to the client his problem started in 2016, when he was 17 years old.
He reported that he was an average student up till Matriculation and his favorite
subject was Urdu. He had many friends and some of them had the habit of smoking.
At the age of 17 years, he lost interest in studies and started to go to the cinema along
with his friends. He got admission in Government College Faisalabad in F.A. He did
not continue studies after his admission and used to spend his time with his friend. His
father and his family asked him to not to indulge in bad company and continue his
studies but he did not listen to them. The client reported that, at the age of 20 years,
his father asked him to do some sort of work, if he did not want to study. For this
purpose, his father decided him to join work at a cloth shop. He ran out of the house at
that time and went to one of his friends. He shared his feelings of hopelessness and
worthlessness with his friend. His friend made him relaxed and asked him to have
cigarette. Initially he refused but later agreed to have one. It was not a tobacco
cigarette rather it was a cigarette filled with chars. The client smoked the cigarette for
the first time. The client reported that he felt fresh, energetic, happy and free from the
feelings of hopelessness and worthlessness. This cigarette provided him instant relief
from the tension. In this way he started having cigarettes. He asked his friends that
how he could buy these cigarettes. They introduced him to those who sell it. The
client reported that as he was unemployed, he did not have money to buy cigarette.
In order to earn some money, he started working at the cloth shop as a sales man.
He used to buy cigarettes through his earning. But due to his poor functioning and
lack of interest, he discontinued going to shop. The client reported that it had been
one year since he was having cigarette of chars. At that time, he had no money to buy
them and developed craving for them. He went to his friend and asked him for money.
His friend instead of giving him money asked him to try alcohol. The client was out
of money, he could not buy cigarette or alcohol. Meanwhile he started to work at tea
stalls. This also boosted his drug taking habit. There he made some friends but they
were also addicts. His company introduced him to other drugs like heroin and chars.
According to the client, at that time he was 23 years old.
Due to his increasing drug intake habit, the symptoms like diarrhea, insomnia,
irritability and fatigue started appearing. His family also became aware of his drug
addiction as his health was deteriorating day by day. His coworkers informed his
parents about his activities and company. He worked there for two years, and then his
father brought him home due to his drug usage but he continued taking heroin and

85
alcohol. With the passage of time, he increased the amount of the drugs as he reported
that the initial amount of dosage became ineffective to him.
According to the informant, at the age of 23 years the client was not allowed by
his father to go out of the premises of the house. He was not given money for any
purpose. His father got him admitted to District Headquarter Hospital, Faisalabad. He
stayed at that hospital for three months from August to October, 2022. His condition
got better and his father sent him to the cloth shop for work again. As he joined the
cloth Shop, he again started taking drugs. The client told that at the cloth shop there
were few people who were addict and he got drugs from them. According to him he
was taking heroin. The client reported that whenever he didn’t take drugs, he had
feelings of headache, irritability, and insomnia. He told that on the unavailability of
drugs he had the feeling that something is missing and he is dying of body pain. Due
to his addiction the owner of the shop decided to fire him and ask his father to send
him to rehabilitation center. Therefore, his family brought him for treatment in Akhtar
Saeed Trust Hospital, Lahore. Actually, he wanted to get rid of his addiction for his
family and especially for his mother therefore, he agreed for treatment.
Background Information
Family history
The client belonged to a low socio-economic class. The client lived in a
nuclear family system. The total number of family members is 10. There were 4
earning members in his family i.e. his father, client, his brother and his mother. The
main authoritative figure in his family was his father. He does not have any sort of
genetic predisposition. The general atmosphere of the house was satisfactory. There
was no such physical or psychiatric illness in client’s family. All the family members
had a satisfactory relationship with each other.
Client’s father was alive. He was 65 years old. He was primary pass. He was a
retired clerk from a school. He was a strict person but loved his children and had a
good relation with the client. His relationship with the client was not so close but is
satisfactory. Father was more attached to the daughters.
Client’s mother was alive. She was 51 years old. She was an uneducated
woman and worked in a garments factory. She was a religious woman. According to
the client, he was attached to his mother and she cared for him a lot as he was the

86
eldest son. The client used to share a lot of things with his mother and she helped him
in various matters.
The relationship between the parents of the client was reported to be
satisfactory. They were cousin in relation. There was a mutual understanding between
them. They were cooperative. His father was the dominant figure in the home. Client
has six siblings i.e. 4 sisters and 2 brothers.
The eldest sister was 30 years old. She was married and had 3 children (2 son
& 2 daughters). She was primary passed. She was a house wife and had satisfactory
relationship with the client. She had no psychological and physical problem. The
second born was also his sister. She was 28 years old, married and had 2 children (2
boys). She was also primary pass and had a satisfactory relationship with the client.
Third born was client itself. He was 27 years old and had done his
matriculation. Fourth born was his brother. He was 26 years old. He was middle pass.
He also worked as a shop keeper. The client had satisfactory relation with him.
Fifth born was his sister. She was 24 years old. She was unmarried and had
done her Intermediate. She had good health and did not have any psychological or
physical problem. She had good relationship with the client. The sixth born was the
brother of client. He was 20 years old and had done his bachelors. He was unmarried
and has good health. The client had a good relationship with him.
Seventh born was his sister, who was 17 years old. She was studying in 11th
class. She was very friendly and client had satisfactory relationship with her.
Physical and psychiatric illness in the family
There was no psychiatric history of illness in the family.
General home atmosphere
The overall home atmosphere was satisfactory, but after his addiction,
everyone was bit aggressive in home. The authoritative person in the home was
client’s father.

Genogram
Figure.1. Pictorial presentation of family relationship

M F

87
 S1
B1
C
S2
B2
S3

S4

Keys
Male (Client, father, and brothers)
Female (Mother and sisters)
Satisfactory relationship
Strong Relationship

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Personal History
Birth and early childhood
According to the informant, the client’s birth was normal without any history
of prenatal and post-natal problems. According to the informant, the client was an
active, naughty and healthy child. He was stubborn and sharp child. There was no
serious illness, hospitalizations, allergies, surgeries, accidents or injury in his
childhood. The informant did not report any neurotic traits like thumb sucking, nail
biting, bed wetting etc. the home environment of client’s house was good.
Educational history
According to the client, his schooling started at the age of five years. He was
admitted in a nearby school at Jaranwala. It was a government school. The client was
satisfied with the school and studies. He was an average student but good in Urdu and
Mathematics. His relation with his teachers was not satisfactory. As according to the
client, his teachers used to point him a lot. He was a naughty student and used to tease
his fellow students and this was not acceptable by his teachers and they used to scold
him. He mostly had quarrels with his fellow students on minor issues. Due to this and
various other reasons he left study after matriculation. He passed his matriculation
board exam by obtaining 596 marks. He had few friends at school. He got admission
in Government College Faisalabad in F.A. He did not continue his studies after
admission as he used to spend most of his time with his friends. The client was not
much social at college and was a bit shy by nature. He was involved in many other
activities, that why he lost his interest in studies. He did not take part in any sort of
extracurricular activities. He left college and didn’t continue the studies.
Occupational history
After doing his matriculation, he did not continue his studies. He worked as a
sales man at cloth shop, first for almost one year in 2016. But could not continue this
and started to work at a tea stall in 2019. This also boosted his drug intake habit. After
treatment he again went to cloth shop in 2022, but due to his drug intake habit he
could not carry his job properly and his father brought him in Akhtar Saeed Trust
Hospital, Lahore.
Socio-economic history

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 The client belonged to a low socio-economic class. The total number of family
members is 10. There were 4 earning members in his family i.e. his father, client, his
brother and his mother. The main authoritative figure in his family was his father.
They were managing their finances properly.
Sexual/ marital history
The client reached puberty at the age of 14. He managed with all the physical
changes he had. He was unmarried and had no sexual history.
Drug / substance-induce history
The client had a history of having cigarettes at the age of 17 years, later on
cigarettes filled with chars, chars and alcohol, and heroin. Currently he came with the
withdraw of heroin.
Forensic history
The client had no forensic history.
Premorbid personality
The client had few friends. He was not a social person. He had satisfactory
relationship with his family and neighbours around. His mood was carefree and
happy. He was sensitive but assertive person. He was a friendly, impulsive, self-
cantered, and stubborn person. He was shy in some situations. He was concerned
about his health and body. He was a moderately religious person. His intellectual
functioning was satisfactory. His decision-making ability was average. He was active
and sharp in his routine functioning. His problem-solving skills were average. He
used to help others before the drug dependence.
Psychological Assessment
Psychological assessment was done in two ways:
1. Informal psychological assessment
2. Formal Psychological Assessment
Informal Assessment
The process of testing that uses a combination of techniques to help arrive at
some hypotheses about a person and their behaviour, personality and capabilities.
These tests come in many types such as written work. It included;
 Behavioural observation
 Clinical interview
 Mental status examination

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 Subjective rating of symptoms
Mental Status Examination
Client’s appearance was tidy and his behavior was calm and satisfactory. He
was cooperative person. He was little suspicious because sometimes he looked at the
note book to see what had been written in it. He had organized and normal form of
thought, normal stream of thought, and focused on his failures. His mood was upset
because he wanted to get rid of addiction. His speech tone was normal and in rhythm.
Client spoke in normal tone and in normal flow. Speech was coherent and
understandable. He answered all the questions properly. The content of the speech
was age appropriated and related to client’s feelings and problems. His responses
were relevant to the asked question. Affect was appropriate to verbal content showed
broad range fluctuation of affect was present and affect changes occurred according to
the topic discussed. His cognitive functions, orientation, were normal. There was no
depersonalization showed by the client. There was no de-realization showed by the
client. There were no obsessions showed by the client. There were no compulsions
showed by the client. The client had no visual and auditory hallucinations and
delusions were not reported by the client. His memory was good and he remembered
childhood experiences. His recent memory was intact. Client’s short-term memory
seemed average as he was able to recall digits that were presented to him verbally. He
could easily recall month, date and years systematically. Client’s long-term memory
seemed satisfactory. As indicated from his case history, client was able to recall
childhood memories affectively. His abstract thinking was average. Client seemed to
have average abstract reasoning. He could easily differentiate and could explain
similarities between two things. On asking about similarity between “guava and
orange” he replied that both were fruits. Similarly, when he was asked about the
difference between “Day and Night” he replied that day was for work and night was
for rest. It reflected his conceptual thinking and ability to distinguish between
essential from nonessential details. He had the average judgmental ability. He had a
proper insight about his problem. His cognitive functions, orientation, were normal.
His general knowledge was average. His insight was adequate. He could register the
things. He built good relationship with the psychologist.
Clinical Interview

91
 Interview is an important tool of assessment. It generates insights and
concepts. It is used to document historical idiosyncratic cases--personalities. It
expands our case understanding. The client and his mother were interviewed for
psychological assessment. He answered all the questions. He told his entire life
history and important life events which lead him to the addiction.

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Subjective rating by client
Table.1.1. Symptoms and pre-Treatment Ratings by client
Symptoms Ratings by client
Strong desire to have heroin 7
Aggression 9
Sleep disturbance 7
Fatigue 9
Craving 7
Restlessness 8
Diarrhea 5
Headache 8

Formal Assessment
Mini Mental Status Examination (MMSE)
A Mini-Mental State Examination (MMSE) is a set of 11 questions that
doctors and other healthcare professionals commonly use to check for cognitive
impairment (problems with thinking, communication, understanding, and memory).
The formal assessment of the client through the MMSE shows no impairment with a
cutoff score of 24.
Bender Gestalt Test (BGT)
The Bender Visual-Motor Gestalt Test (abbreviated as Bender-Gestalt test) is
a psychological test used by mental health practitioners that assesses visual-motor
functioning, developmental disorders, and neurological impairments in children ages
3 and older and adults. The test consists of nine index cards picturing different
geometric designs. The cards are presented individually and test subjects are asked to
copy the design before the next card is shown. Test results are scored based on the
accuracy and organization of the reproductions. Scoring on BGT shows a cutoff score
of 2 score and depicts the no vasoconstrictive deficits and brain impairment.
Thematic Apperception Test (TAT)
The Thematic Apperception Test (TAT) is a projective psychological test
developed during the 1930s by Henry A. Murray and Christiana D. Morgan at
Harvard University. Proponents of the technique assert those subjects' responses, in
the narratives they make up about ambiguous pictures of people, reveal their

93
underlying motives, concerns, and the way they see the social world. The patient's
self-image is fragile and vulnerable, indicating a sense of helplessness and
powerlessness. This is reflected in the TAT story, where the boy appears lost and
disconnected from his violin, symbolizing a sense of disconnection from their own
life and purpose. The patient's dominant needs are for escape, comfort, and relief.
This suggests a craving for immediate gratification and a desire to numb emotional
pain. The TAT story highlights the need for a sense of control and escape.

The patient's main conflicts revolve around autonomy vs. dependence, self-
control vs. impulsivity, and pleasure vs. pain. This indicates struggles with addiction,
self-regulation, and the need for instant gratification. The TAT story shows the
conflict between the desire to play the violin (autonomy) and the inability to do so
(dependence on opioids).The patient's anxieties center on fear of withdrawal, pain,
and loss of control. The patient may have conflicts with their caregiver figures,
indicating a sense of abandonment or neglect. This could contribute to their need for
escape and comfort through substance use. The patient's environment is perceived as
chaotic and unpredictable, leading to feelings of anxiety and desperation. The TAT
story depicts a bleak and isolated atmosphere, reflecting the patient's emotional state.
The patient uses defense mechanisms like denial, rationalization, and projection to
cope with anxieties and conflicts. This patient's TAT report suggests an individual
struggling with opioid addiction, low self-esteem, and a need for escape and comfort.
They fear withdrawal, pain, and loss of control, and have conflicts with autonomy and
self-regulation. Defense mechanisms like denial and rationalization are used to cope
with these anxieties.

Standard Progressive Matrices (SPM)

The Standard Progressive Matrices (SPM) is a group or individually

administered test that nonverbally assesses intelligence in children and adults through
abstract reasoning tasks. It is sometimes called Raven's, although the SPM is only one
of three tests that together comprise Raven's Progressive Matrices. Appropriate for
ages 8-65, the SPM consists of 60 problems (five sets of 12), all of which involve
completing a pattern or figure with a part missing by choosing the correct missing
piece from among six alternatives. Patterns are arranged in order of increasing
difficulty. The test is untimed but generally takes 15-45 minutes Assessment of

94
intelligence and abstract reasoning revealed that the client has average intellectual
capacity as his score falls in grade definitely average.

Human Figure Drawing (HFD)

The figure is drawn with restless and agitated lines, suggesting a sense of inner
turmoil and discomfort. The patient may be feeling restless and unable to relax. The
drawing includes heavy and dark lines, indicating fatigue and exhaustion. The patient
may be feeling drained and depleted. The figure includes aggressive and distorted
facial features, indicating irritability and aggression. The patient may be feeling short-
tempered and prone to outbursts. The figure includes elements that suggest insomnia
and sleep disturbances, such as dark circles or uneven lines, indicating a disrupted
sleep pattern. The patient may be struggling to fall asleep or stay asleep. The figure
reveals a mix of chaotic and rigid elements, suggesting a struggle between emotional
expression and constriction. The patient may be feeling overwhelmed by their
symptoms and struggling to cope. The figure includes elements that suggest anxiety
and stress, such as tense lines or fragmented shapes. The patient may be feeling
overwhelmed and struggling to manage their emotions. This HFD report suggests that
the opioid withdrawal patient is struggling with restlessness, fatigue, physical
discomfort, irritability, aggression, frustration, and insomnia. The results indicate a
need for emotional regulation, coping mechanisms, and support during this
challenging time.

Rorschach Inkblot Test (ROR)

The Rorschach test is a projective psychological test in which subjects'
perceptions of inkblots are recorded and then analyzed using psychological
interpretation, complex algorithms, or both. Some psychologists use this test to
examine a person's personality characteristics and emotional functioning. It has been
employed to detect underlying thought disorder, especially in cases where patients are
reluctant to describe their thinking processes openly. The result indicates a
preoccupation with death, hopelessness, and despair, reflecting the individual's
emotional state during opioid withdrawal. It suggests a sense of disintegration,
fragmentation, and loss of control, mirroring the individual's experience of opioid
withdrawal. The patient Emphasis on darkness and shading that Indicates a focus on
the negative aspects of life, reflecting the individual's emotional pain and distress

95
during withdrawal. Lack of color and vibrancy suggests emotional numbness,
dullness, and a lack of joy, consistent with the individual's experience of opioid
withdrawal. The test reveals intense emotional suffering, feelings of being
overwhelmed, and emotional exhaustion, characteristic of opioid withdrawal. The
individual's responses suggest a tendency to disconnect from others, withdraw from
social interactions, and feel isolated, consistent with the experience of opioid
withdrawal. The test indicates underlying anxiety and insecurity, leading to
difficulties in coping with the withdrawal process.

Diagnosis
According to the Diagnostic and Statistical Manual 5 (DSM-V), the client was
diagnosed with Opioid Withdrawal 292.2(F11.23)
Table.1.4. Shows the Diagnosis
Diagnosis Code
Opioid Withdrawal 292.2 (F11.23)
Prognosis
In the M.F case the chance of cure in future was bright and prognosis was very
good. The need was to develop the great insight in his family member that they would
not label him mentally ill after the recovery. Although the client’s family was
supportive. The client was also cooperative and willing to change. He wanted to quit
drugs and was following the therapeutic plan.

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Case Conceptualization
Beck (1993) Cognitive model of substance use

Activating Stimulus

Core belief

Automatic thought

Cravings

Facilitating thought

Focus on Instrumental strategies

97
Idiosyncratic Beck (1993) Cognitive model of substance use

Activating Stimulus
Sitting with friends

Core belief
I should smoke with friends. I need it no matter what.

Automatic thought
I should take drug it gives me pleasure and relief. I should enjoy
it with friends.

Cravings
I can control my cravings but not for too long, when I sit with
friends, I crave for it.

Facilitating thought
I should take drug, my friends are also having it. I will feel happy
and peaceful.

Focus on Instrumental strategies

Lost job and healthy relationship with family. He used to spend
more time with friends instead of family.

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Case Formulation
The client was 25 years old young man of normal height and thin built. His
education was matriculation. He discontinued studies because of increasing interest in
other activities with his friends. He used to sit much with his friends and they started
using cigarettes and later on alcohol. Meanwhile, client did many jobs in order to earn
some money. He worked as a sales man and also worked at a tea stall. He was also
admitted to hospital for his treatment for three months. After recovering he started his
job, there he became addict once again as some of his fellow workers also used drugs.
The client then started using chars and this caused him a lot of health issues. Later on,
he started using heroin that also became the cause of his job problems. His family
came to know about his addiction and took him to Akhtar Saeed Trust Hospital,
Lahore for treatment purpose. His MSE revealed that his attention and concentration
was normal. He maintained his hygiene. His appearance was consistent with his
chronological age. His gait and speech were normal. He had intact remote, recent
memory
Drugs act as positive reinforcers because they cause positive subjective
experiences such as euphoria or reduction in anxiety (Gelder, Mayou & Cowen.,
2001). The client reported that the use of drugs provided him feeling of relief and
calmness. Without any social and cultural influences, alcohol is very pleasurable
(Durand and Barlow, 1997).
Psychodynamic theorists believe that people who ultimately abuse substance
have inordinate dependency needs traceable to their early years. They theorize that
when parents fail to satisfy a child’s need for nurturance, the child is likely to go
through life in a dependent manner relying too much on others for support, help and
comfort in an effort to find the nurturance he or she did not receive as a child. If this
search for external sources of support includes experimentation with a drug, such a
person is likely to develop a dependent relationship with the substance (Comer,
1995). It was consistent with client’s life history as his parents did not monitor his
early life activities properly. So, in order to compensate himself emotionally the client
depended on drugs.
When the client started using drugs his age was around 17 years old. It has
been reported that individuals between ages 18-24 years have relatively high
prevalence rates for the use of virtually every substance, including alcohol (APA,

99
2000). This was consistent with client’s case as he started using drugs at the age of 17
years.
Substance related disorders are usually diagnosed more commonly in males
than in females (APA, 2000) gender differences are there in drug addiction. This fact
played a role of predisposing factor in client’s case. In western countries, about three
times as many men as women suffer from alcohol misuse and dependence, but in
Asian and Hispanic cultures over ten times as many men are affected (Helzer and
Canino, 1992 as cited in, Gelder, mayou & Cowen, 2001).
Peer influences are important in the use of drug (Davison & Neale, 1997). In
this case, the client was introduced to chars, alcohol, and heroin by his friends. And
he used to get all the relative information about drugs through his friends. The client
had a bad company and it served as a precipitating factor in this case.
Solomon (1980) holds that the brain is structured in such a way that
pleasurable emotions such as drug induced euphoria, inevitably lead to opponent
processes, negative after effects that leave the person feeling worse than usual. People
who continue to use pleasure giving drugs inevitably develop opponent after effects
such as craving for more of the drug withdrawal responses and an increasing need for
the drug. According to Solomon, the opponent processes eventually dominate and
suppress the pleasure giving processes and avoidance of the negative after effects
replaces pursuit of pleasure as the individual’s primary motivation for taking drugs
(Peele, 1989 as cited in, Comer, 1992). It seemed to be consistent with the client
addiction as in order to gain soothing, calming and euphoric effects he shuffled from
one drug to another, although he felt many negative consequences of a new drug use.
Initially he experienced pleasure that pushed him to continue taking drugs.
A number of socio-cultural theorists propose that the people most likely to
develop patterns of substance abuse or dependence live under stressful socioeconomic
conditions (Comer, 1992). This aspect was also consistent with the client’s situation,
as he had stressful socioeconomic conditions and had to struggle a lot to earn and
financially support his family. He shifted from one job to another. In this case gender
and socioeconomic influences might be the predisposing factors.
Some psychodynamic theorists also believe that certain people develop a
“substance abuse personality” that makes them particularly vulnerable to drugs.
Studies have found that people who abuse or depend on drugs tend to be more
dependent, antisocial, impulsive and depressive than other people (Shedler & Block,

100
1990; Grinspoon &Bakalar, 1986; Labouvie & McGee, 1986; Gilbert &Lombardi,
1967 as cited in, Comer, 1992). The client’s personality was also impulsive and he
was not very social. He had dependent and aggressive personality. Here his
personality was another predisposing factor.
In the present case the client reported that he used to take just alcohol and
cigarettes in the beginning but with the passage of time he used to develop the need
for more and more and due to this he started using chars and heroin. When a person
takes a drug for a long period of time, he will need more to achieve the same results
(Durand & Barlow, 1997). According to comer, 1992, the rewarding effects of
substance may also lead users to eventually try higher dosages or more powerful
methods of ingestion. When the client used heroin, he started to take it by volatilizing
it on a paper. The vaporous form of drug intake is relatively more severe.
In this case various factors like socioeconomic influences, age, gender and
personality traits were serving as predisposing factors. Whereas the client’s peer
group and discontinuation of studies as the result of conflicts with teachers served as
precipitating factors. The client’s experience of calmness, relaxation, tension free
feeling and stress reduction were contributing in the maintenance of his problem. The
support of client’s family and the guilt and willingness of client towards change were
protecting factors.
Management Plan
The management plan included:
1. Short term treatment
2. Long term treatment
Short term Goals
Short Term Goals Therapeutic Intervention
 A relationship was built with the  Rapport Building
client that was a therapeutic
relationship established to break the
resistance.
 Deep breathing and progressive  Relaxation
muscle relaxation were taught to the
client that helped him to relax.
 Psycho-education was provided to the  Psycho-education

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 client and informant in order to
understand the problem and the
process of treatment.
 The client was asked to take  Medication Adherence
medicines on time according to the
prescription of psychiatrist.
 Supportive psychotherapy was done,  Supportive Psychotherapy
to encourage client to take 
responsibility for his own actions and
to work out solutions to their
problems.
 To fight with the craving, coping  Craving Management
strategies were taught to the client to
manage his cravings.
 The sleep hygiene was described to  Sleep hygiene
the client, so he could schedule and
built healthy sleeping habits.
 Problem solving steps were taught to  Problem Solving
the client, so he could understand and
solve his problems on his own.
 Counselling was done to help him  Individual Counselling
maintain long term sobriety, also to
help overcome the unique personal
difficulties which lead to drug or
alcohol addiction.
 Family counselling sessions were  Family Counselling
conducted to increase the family
support to increase the chances of
recovery.
 Anger management was described to  Anger Management
the client to manage his emotions,
learn to control reactions and
physiological arousal.
 It helped the client to understand that  ABC Model

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 our emotions, feelings are caused by
our thoughts and not by any event or
others.
 To help client identify early signs of  Relapse prevention
problem and how to deal with them.

Long term treatment

 Establish a sustained recovery, free from the use of any drug or mood-altering
substances.
 Continuation of all the learned behaviour and methods to maintain recovery and
generalize them in everyday life.
 Improve quality of personal life by maintaining abstinence from all the addictive
substances.
 Regular follow up sessions will be conducted to keep a check on his schedule.
Summary of Therapeutic Interventions
Rapport building
Rapport is a relationship with the client. It can be considered as harmonious
understanding with the client. Building rapport is a process of developing that
connection with the client. It usually based on shared experiences or views, including
a shared sense of humor. Building rapport tends to be the most important at the start
of therapeutic relationship. Rapport is built through active listening, respect,
empathy, validation, honesty, competency, meet at their level, and setting small goals.
Deep Breathing
Deep breathing helps to deal with symptoms of numbness and fatigue. Firstly,
the rationale of deep breathing was told to the client. Then deep breathing was taught
to the client by verbal instruction and the demonstration to induce relaxation and
release from stress. (HealthLibrary. (2020))
 Sit in a relaxed position and close the eyes.
 Hold to inhale from the nose, hold for few seconds then exhale from the mouth.
 Repeat the procedure three times.
Psychoeducation

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 Psychoeducation is a form of education that is specifically offered to
individuals who are suffering from any one of several distinct mental health
conditions impairing their ability to lead their lives. The ideal aim of the
psychoeducational approach is to give both the individuals who suffer from
psychological conditions and their families a stronger base of knowledge for knowing
on ways to cope and thrive despite the condition (Best Counseling degrees. (2020)).
The psychologist gave an insight into the client’s problem so, he could be better able
to deal with his problems.
Medication Adherence
The client was guided about the importance of medicine that how it reduces
the symptoms and lowers the relapse chance. It helps to follow the medical advice
properly and if notice any side effect, it should be informed to the doctor. The client
would not stop taking medicine without the consultation of her doctor.

Supportive Psychotherapy
Supportive psychotherapy helps by encourage the patients to talk about their
problems while the therapist listens sympathetically. The therapist offers prestige
suggestions by encouraging the patient to take responsibility for his or her own
actions and to work out solutions to their problems. The therapist give trust full
reassurance about prognosis. (Gelder, Gath, Mayou, 1985). The main goal of a
supportive therapy is to build a therapeutic alliance, which can be conceptualized as:
1. Bond between the client and therapist
2. Agreement on the tasks and goals of the therapy
3. Client’s capacity to perform the therapeutic work
4. Therapist’s empathic relatedness and involvement
Activity Schedule
A list of activity schedule was prepared with the help of client. He was asked
to mention his daily activity at the end of the day regularly. Activity scheduling is one
of the simplest behavioral interventions in the CBT approach (Padesky&Greenberer,
1995). Daily activity chart was provided to the client. The client had to follow every
task mentioned to him so, it could help the client to involve him in activities and
improve his behavior.

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Relaxation Exercise
The client was trained with 16 muscles relaxation training exercise and deep
breathing to manage his problem. Encouraged the client for better performance and
involvement in the healthy activities. The aim was to guide the client to control stress
(experienced in the form of physical, emotional, cognitive symptoms) by countering
the tonic contraction of muscle fibers. Relaxation exercise was used to reduce his
anxiety level to manage withdrawal pains and to induce deep muscle relaxation, thus
improving the quality of sleep (Jongsma and peter, 2006).
Cognitive Behavioral Therapy (CBT)
CBT is a therapeutic approach to helping resolve emotional and behavioral
disturbances in client by working with their cognitive and behavioral responses to
internal and external events. Beck developed his cognitive therapy from his clinical
experiences with depressive patients. CBT is based on the idea that how we thin
(cognition) how we feel (emotion) and how (behavior) all interacts together.
Specifically, our thoughts determine our behavior. Therefore, negative and unrealistic
thoughts can cause us distress and result in problems (Burns,1980).
Individual Counseling
Participating in individual counseling can be an excellent way to maintain
long term sobriety and many clients find it a very rewarding experience. Counselling
can help an addict overcome the unique personal difficulties which lead to drug or
alcohol addiction. Through counseling a psychologist helps set personal, familial and
professional goals for the client so growth and success continue in sobriety, further
solidifying a happy life.
Craving Management
Craving is broadly defined as the desire to use alcohol or other drugs; it
increases the likelihood of use of these substances. In the CIM Model treatment
interventions are referenced to craving, i.e., helping clients to identify their craving
level and equipping them with strategies to avoid use. Four causes of craving are
identified:
(1) environmental cues (triggers): exposure to people, places, and things associated
with prior drug-using experiences may cause immediate and overwhelming craving;
(2) stress: addicted persons experience stress as craving;
(3) mental illness; and

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(4) drug withdrawal: symptoms of both mental illness and withdrawal lead to craving
if clients associate use with relief of these symptoms.
Sleep hygiene are ways to set up yourself for good sleep. Sleep hygiene is
important for both physical and mental health, improving productivity and overall
quality of life. Optimizing your sleep schedule, pre-bed routine, and daily routines is
part of harnessing habits to make quality sleep feel more automatic.
ABC Model
The individual’s interpretation of events determines how he feels and behaves
(Leahy, 2003). ABC model was explained to the client by therapist. The relationship
between activating event, belief/thought and resulting emotions and consequences
were explained to the client. It was also explained to the client to help him develop
alternative ways of thinking and behaving which can reduce his psychological
distress.
ABC model was explained with the help of examples and also with events
from his base line and A-B-C connection was build. It was made clear to client that
our emotions, feelings are caused by our thoughts and not by any event or others.
Client understood the connection after explanation and examples provided by
therapist.
Problem Solving
Problem-solving is a form of therapy that provides client with tools to identify
and solve problems that arise from life stressors, both big and small. Its aim is to
improve your overall quality of life and reduce the negative impact of psychological
and physical illness. Problem-solving therapy is very practical in its approach and is
only concerned with the present, rather than delving into your past. It includes
discovery (finding a solution), performance (implementing the solution), and
verification (assessing the outcome).
Family Counseling
Family counseling provides family members with guidance, training, practical
advice education about depression and emotional support and empathy. It helps
family members become more realistic in their expectations, more tolerant less guilt
ridden, and more willing to try new patterns of interaction and communication.
Family counseling often succeeds in improving communication and reducing tension
within the family (Comer, 1992). The procedure is usually combined with the

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education about illness and its consequences, together with practical advice on
management. Family counseling can be useful to treat the patients with conversion
because it involves the family members as well as the client. According to this
technique, the family and the client to be educated about the disorder that it is a
biological imbalance that will “normalize” the disordered person and make it less
frightening so that everyone can deal with it more realistically (McFarlane, 2007).
Anger Management
Anger management is the process of learning to recognize signs that you're
becoming angry, and taking action to calm down and deal with the situation in a
productive way. The purpose of anger management is to help a person decrease
anger. It reduces the emotional and physical arousal that anger can cause. It is
generally impossible to avoid all people and settings that incite anger. But a
person may learn to control reactions and respond in a socially appropriate
manner. The support of a mental health professional may be helpful in this
process.
Relapse Prevention
Relapse prevention typically consist of checking for residual belief in negative
automatic thoughts and challenging them the reversal of any remaining avoidance tied
to target fears is also undertaken (Wells,1997) The verbal challenges were used for
negative beliefs. It included strategies to maintain and remained the termination of
treatment.

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