1

Case No 1
Major Depressive Disorder
Bio Data
Name M.K
Age 22years
Gender Female
Education 7th
Marital Status Single
No of siblings 4
Birth Order 4th
Family System Nuclear
Religion Islam
Occupation Nill
Socioeconomic Status Middle Class
Reason for Referral
The client was referred with the complaint of lake of interest in daily activities, low
mood; disturb sleep, low frustration tolerance and suicidal thoughts. For the further assessment
and management she was referred to the trainee clinical psychologist.
Presenting Complaints
Duration Complaints
6 months Lack of interest in daily activities
6 months Low mood
Disturbed sleep (trouble falling asleep, early morning
4 months
awakening)
4 months Loss of appetite (14 pounds weight loss without dieting)
3–4 months Low energy and fatigue
3–4 months Difficulty concentrating
Irritability and emotional outbursts (e.g., sudden weeping,
3–4 months
quarrelling)
2–3 months Social withdrawal and isolation
 2

Duration Complaints
2 months Suicidal thoughts and hopelessness

History of Present Illness

The client’s problem started 6 month back after her engagement. The family was relative
to the client’s family. Client was happy after her engagement but her elder brother was not
agreed for this engagement. He leaves the house in anger. Client’s elder brother wants to well
settle family for her sister but client’s fiancé was a motor mechanic. After the continuously
arguments of her elder brother, her parents refused to them for this marry against her willing.
Client wanted to marry with him, so she was very disturbed after that decision. She wanted to
share her problem with her elder sister but didn’t because of her serious condition due to
delivery. After 2 months her brother also attempt the suicide due to the family strictness and
demand of love marriage as the client had. This sudden death shocked her. She started to keep
quite most of her time and stopped to talk with her family members. She started to remain alone.
She had lost of her interest in life about four months before at the end of her relationship with her
fiancé.
Her mother reported that she started weeping whenever they talk to her marriage. She
was much disturbed in those days. She was quarrelled with her mother without any reason and
after that started weeping. She had lost 14 pounds without dieting because she did not feel like
eating.
Her mother also reported that she had trouble falling asleep almost every night and woke at 3:00
a.m. every morning (she normally woke at 6:30 a.m.) She had low energy, trouble staying
focused and has less ability to do daily functioning.
Her parent’s decision affected her life and she started thinking about death. She stated
that she was losing all the hope of happiness in her life and she did not care about anyone. She
stopped taking a part in daily activities like go outside with family outing and her social
connection was also affected. She preferred to be alone.
The client’s family approached a religious healer for her spiritual treatment but her condition
became worse. So the family of client took her to the Al Noor Hospital for the treatment and
management.
 3

Birth Order
Client is the youngest of four siblings. Being the last-born, she was often emotionally
supported by her elder brothers and sister, which nurtured a dependent and sensitive
temperament. She was not required to take on major responsibilities, allowing her to stay
emotionally expressive and closely attached to her immediate family members. This early role
influenced her need for external validation and emotional security. The loss of her brother—
whom she admired and relied upon—left her feeling abandoned and unsupported, significantly
affecting her emotional well-being and contributing to the development of depressive symptoms
in young adulthood.
Childhood
Client described her childhood as calm and emotionally secure. She was raised in a
middle-class, nuclear family where her parents were attentive and fulfilled her basic emotional
and physical needs. Although her father lived separately with his second wife, he remained
financially supportive and emotionally present, which helped maintain family stability.
She was described as a quiet, obedient child who enjoyed household tasks and indoor activities
like stitching and watching television. Client was not socially active and had only a few close
friends, preferring the comfort of home.
Her mother reported no behavioral problems or emotional disturbances during childhood.
However, client sensitive nature and reserved personality made her more dependent on
emotional support from close family members. While she did not experience any trauma during
childhood, this emotional sensitivity may have contributed to her difficulty managing loss and
rejection in later life.
Educational History
Client began her formal education at the age of five and was enrolled in a local school.
She progressed through her academic years without any reported learning difficulties or
behavioral concerns. Her mother described her as an average student who performed reasonably
in her studies but did not show significant academic achievements.
She was educated up to the 7th grade and later completed F.A., indicating some
inconsistency in reported academic progression, possibly due to gaps or informal learning
pathways. M.K. showed more interest in household tasks than academic success and preferred a
structured home environment over the demands of school life.
 4

Although she was not reported to face any peer conflicts, her limited social interaction at
school mirrored her reserved personality. There is no history of disciplinary actions or school
refusal. Overall, her educational experience appeared stable but lacked enthusiasm or goal-
oriented ambition.
Premorbid Personality
Client was described as a sensitive, quiet, and emotionally expressive individual prior to
the onset of her current symptoms. She maintained a calm and composed demeanor and was not
prone to anger or impulsive reactions. She preferred staying within the comfort of her home
environment, engaging in domestic tasks such as stitching and knitting, which provided her with
a sense of structure and emotional security.
Socially, she was reserved and maintained limited friendships, showing a preference for a
small circle of trusted individuals. Her non-assertive nature often made it difficult for her to
express her needs or disagreements openly, which contributed to internalized emotional distress
during interpersonal conflicts.
She was known to be religiously inclined, regularly offered prayers, and found comfort in
spiritual routines. Her premorbid functioning indicated a balanced but emotionally dependent
personality, which may have increased her vulnerability to distress following relational loss and
family discord.
Marital History
Client is currently single and has not been married, though she was engaged
approximately six months ago to a relative with whom she shared a close emotional bond.
Initially content with the engagement, her emotional well-being declined when her elder brother
strongly opposed the match due to the fiancé’s occupation and social status. After repeated
family conflicts, her parents ended the engagement against her wishes, leaving her emotionally
devastated. The situation worsened when her brother later died by suicide—an event reportedly
linked to ongoing family stress related to love marriages. These consecutive relational and
familial losses significantly contributed to the emergence of her depressive symptoms.
Occupational History
Client has no formal occupational history. She has never been employed and remained
primarily engaged in household tasks and leisure activities such as stitching and knitting. Due to
her limited educational background and traditional family environment, no vocational training or
 5

work opportunities were pursued. Her current psychological condition, including low energy,
lack of motivation, and social withdrawal, further impairs her ability to initiate or maintain any
form of occupational activity. Prior to the onset of symptoms, she showed some interest in
domestic responsibilities, but her functional capacity has significantly declined in recent months.
History of Family Psychiatric/Medical Illness
Client reported no formally diagnosed psychiatric disorders in her immediate or extended
family. However, emotional struggles were often dealt with privately, and mental health
concerns were not openly addressed. Her family’s initial preference for spiritual treatment rather
than psychological support highlights a cultural tendency to avoid professional intervention in
emotional matters. While no psychiatric conditions have been identified in relatives, the suicide
of her elder brother suggests unacknowledged psychological distress within the family system.
There is no significant record of chronic physical illness except for routine health issues related
to age and occupation among family members.
Assessment
The client was assessed across multiple domains to obtain a comprehensive understanding of
her emotional, cognitive, and behavioral functioning. A combination of structured and semi-
structured methods was used to gather clinically relevant data. The assessment process involved
the following techniques:
 Mental Status Examination
 Clinical Interview
 Subjective Symptom Rating Scales
 Beck Depression Inventory (BDI)
 Rotter’s Incomplete Sentences Blank (RISB)
These tools collectively provided insight into the client’s current psychological state, cognitive
distortions, and level of emotional disturbance, which guided both diagnostic formulation and
future management planning.
Mental Status Examination
The mental status examination was conducted to assess the client’s current cognitive,
emotional, and behavioral functioning. The client appeared her stated age and was appropriately
dressed. Her hygiene and grooming were adequate. She maintained intermittent eye contact and
exhibited a withdrawn demeanor, with psychomotor retardation noted throughout the session.
 6

Her mood was reported as “low” and her affect was constricted, congruent with the reported
emotional state. She appeared anxious and occasionally tearful during the interview. Speech was
relevant and coherent, though slow in pace and low in volume. Thought process was goal-
directed with no evidence of formal thought disorder. There were no perceptual disturbances
such as hallucinations or delusions observed or reported.
The client was oriented to time, place, and person. However, she exhibited noticeable
difficulty in sustaining attention and concentration. Her recent memory seemed impaired, while
remote memory remained intact. Judgment and insight were present but limited; she was aware
of her emotional distress but struggled to understand its full impact on her daily functioning.
Abstract thinking was within normal limits.
Clinical Interview
The clinical interview served as a foundational component in gathering detailed
psychological, emotional, and contextual information about the client. Conducted with both the
client and her mother, the interview aimed to understand the presenting complaints, the onset and
development of symptoms, and the psychosocial stressors contributing to her current condition.
It provided valuable insight into her family dynamics, personal history, academic and
occupational background, and premorbid personality traits.
Information was obtained through a semi-structured format, allowing for both guided
questioning and open-ended discussion. The interview explored predisposing, precipitating, and
maintaining factors of her emotional disturbance, as well as protective elements that could
support recovery. Special attention was given to her emotional responses to relational loss,
particularly the breakdown of her engagement and the suicide of her brother—events that
appeared to mark the onset of significant psychological decline.
The client presented as cooperative but emotionally withdrawn. Her responses were
coherent yet marked by noticeable sadness, slow speech, and intermittent tearfulness.
Observations during the interview complemented the psychometric data, reinforcing the presence
of depressive symptoms. The interview process also served to initiate therapeutic rapport,
offering a safe space for emotional expression and beginning the process of case
conceptualization.
 7

Subjective Rating
Subjective rating scale is widely used in almost every aspect of ergonomics research and
practice for the assessment of workload, fatigue, usability and lesser known qualities such as
urgency and presence. (Annet, 2002).
Subjective rating scale was used to the client to rate her symptoms. The client asked to rate her
symptoms on 0 to 10 point scale after explaining the rationale and purpose of this assessment.
Symptoms Rating (0–10)
Difficulty Concentrating 8
Hopelessness 9
Dizziness 8
Lack of Interest 8
Irritability 9
Sadness and Anxiety 9
Suicidal Thoughts 8

Beck Depression Inventory(BAI)

The Beck Depression Inventory created by Aaron T. Beck, is a 21 question multiple
choice self report inventory, one of ther most widely used psychometric tests for measuring the
severity of depression. (G Jackson, 2016)
Quantitative Interpretation

Measure Score Range Severity Level

Depression 41 29-63 Severe Depression

Qualitative Interpretation
Beck depression inventory was administered to the client. Her score was 41 which
indicated that client had severe level of depression.
Rotter Incomplete Sentence Blank(RISB)
The Rotter Incomplete Sentences Blank (RISB) is a widely used projective technique
designed to assess personality adjustment and emotional functioning. This performance-based
 8

tool helps in identifying adjustment difficulties, forming diagnostic impressions, and guiding
therapeutic intervention.
Rotter Incomplete Sentences Blank (RISB) – Scoring Table

Code Category No. of Responses Score per Response Total Score

P1 Positive 5 2 10
P2 Neutral 3 1 3
C1 Mild Conflict 11 4 44

C2 Moderate Conflict 21 5 105

Total 40 160

Qualitative Interpretation
Rotter’s Incomplete Sentences Blank test was administered to the client. Her score on this
test was 160, while the cut-off score was 135, indicating a significant level of maladjustment.
The elevated score reflects underlying emotional disturbances, interpersonal difficulties, and
possible personality conflicts. Her responses revealed patterns of low self-worth, interpersonal
mistrust, and negative thinking, suggesting that the client is struggling with internalized distress
and inadequate coping mechanisms. These findings highlight the need for further psychological
support and intervention-focused therapy.

Case Formulation
Predisposing Factors
Client has always been emotionally dependent on her close family members, especially
her elder brother. She was the youngest at home and had limited exposure to external challenges
or responsibilities. Growing up in an emotionally reserved household, she didn’t learn how to
openly express her feelings. Her quiet personality, strong emotional attachments, and lack of
early emotional independence made her more vulnerable to emotional disturbances later in life.
According to psychodynamic theory, early loss or emotional deprivation can contribute to the
development of depression (Lewis, 1950). In client case, her dependency and emotional
repression made her prone to depressive symptoms when major life stressors occurred.
 9

Precipitating Factors
Client symptoms of depression were triggered by two significant life events. First, her
engagement was broken by her parents against her will, even though she was emotionally
attached to her fiancé. Second, her elder brother, who was a major source of emotional support,
died by suicide. These back-to-back events left her feeling helpless, rejected, and emotionally
broken. Research suggests that stressful life events, especially related to loss and rejection, are
strongly linked with the onset of Major Depressive Disorder (Cohen, 2004). Her emotional
collapse after these events aligns with DSM-5 criteria, which require at least five depressive
symptoms occurring during the same two-week period, such as low mood, sleep disturbance, loss
of interest, fatigue, and suicidal ideation (American Psychiatric Association, 2013).
Perpetuating Factors
Client symptoms worsened over time because she did not talk about her feelings or seek
support. She became socially withdrawn, remained quiet, and showed no interest in daily life.
She often stayed in her room, cried frequently, and expressed hopelessness. These behaviors
further reinforced her depression. Additionally, her family initially sought help from spiritual
means rather than clinical support, which delayed proper treatment. Her symptoms, such as
fatigue, sleep disturbance, lack of interest, and feelings of worthlessness, continued
unchecked, as described in studies by Johnson (2005), who noted that individuals with MDD
show a loss of pleasure and daily functioning even without current stressors.
Protective Factors
Despite her condition, client has some strengths that can support her recovery. Her
mother is concerned about her mental health and has now taken steps to bring her for therapy.
Client also enjoys stitching and household activities when her mood is better, which can serve as
constructive coping outlets. She maintains religious values, which may provide comfort and
purpose in the healing process. These factors, along with the beginning of a therapeutic
relationship, offer a foundation for emotional recovery.
Diagnostic Formulation
Based on clinical interviews, behavioral observations, and psychological assessments
(including the BDI and RISB),client meets the criteria for Major Depressive Disorder as per
the DSM-5. She displays more than five key symptoms including persistent low mood, loss of
interest, sleep disturbance, fatigue, and suicidal thoughts—all of which have lasted longer than
 10

two weeks and significantly impact her daily functioning. There is no evidence of a medical
illness or substance use, making it a primary diagnosis. The presence of major life stressors (e.g.,
relationship loss, death of a loved one) aligns with Kessing & Agerbo (2004) who found that
general family loss and traumatic life changes increase the risk of depression.
Her symptoms also reflect psychodynamic patterns of unresolved grief and loss, particularly
after her brother’s death (Lewis, 1950), and her emotional shutdown following rejection further
confirms the likelihood of a depressive episode
Counselling Processes
Rapport Building
A strong therapeutic alliance was cultivated through consistent use of verbal and non-
verbal cues that conveyed empathy, warmth, and unconditional positive regard. The client was
encouraged to express her concerns freely, without fear of judgment or invalidation. Early
interactions involved reflective listening, empathic mirroring, and tone modulation to reinforce
emotional safety. Cultural and contextual sensitivity was prioritized to align the therapeutic
approach with the client’s background, beliefs, and unique worldview.
The practitioner made deliberate efforts to validate even the subtlest emotional cues expressed by
the client, facilitating a sense of being deeply understood. Through appropriate eye contact, open
body posture, and gentle vocal affirmations, the therapeutic environment was consciously shaped
to promote psychological safety. Trust was further reinforced by respecting the client’s pace and
avoiding pressure to disclose sensitive information prematurely. These cumulative efforts
increased the client’s openness to therapeutic tools and allowed her to engage in a collaborative
manner.
To enhance consistency, brief check-ins were held at the start of each meeting to
acknowledge any changes in emotional state or recent challenges. These check-ins further
deepened the bond and created a rhythm of emotional continuity. Rapport was sustained not just
during structured dialogue but also through small transitional moments, such as pauses, silences,
and reassurance, which were handled with care. As a result, the client began to share emotionally
painful memories, including guilt, grief, and fear, with increased confidence and resilience. The
trust built in this space became a cornerstone for the success of all therapeutic strategies.

Psychoeducation
 11

The client and her caregiver were given structured and interactive education that clarified
the nature and impact of her emotional difficulties. Psychoeducation began with simple
explanations about the psychological and physiological symptoms of acute stress, including
changes in mood, sleep, appetite, and attention. Diagrams of the stress response system,
including the amygdala, prefrontal cortex, and autonomic nervous system, were used to explain
how emotions affect the body. This visual approach enabled both the client and caregiver to
understand the science behind her feelings.
Real-life analogies, such as comparing the stress response to a smoke alarm, were used to
normalize her reactions and diminish fear around her emotional responses. The therapist actively
engaged both the client and caregiver through questions and discussion, ensuring their
understanding of key concepts. The process also involved identifying the difference between
helpful and unhelpful coping behaviors and reinforcing the role of emotional regulation
techniques. Personalized handouts were created to reinforce learning and were used for home
reference.
The caregiver’s involvement was instrumental in reinforcing psychoeducation outside the
therapy setting. She was taught to respond with empathy rather than discipline when the client
displayed irritability or withdrawal, and this shift in response lowered home-based tensions.
Misinterpretations of client behaviors, such as assuming she was being lazy or defiant, were
clarified and reframed as stress-driven responses. This not only supported the client’s emotional
healing but also improved family dynamics, fostering a more cohesive support network.
Ultimately, psychoeducation empowered the client to interpret her emotions as
manageable signals rather than overwhelming threats. It fostered hope, increased her confidence
in recovery, and created a shared language for the therapeutic work. As both client and caregiver
became more informed, they took active roles in applying coping strategies and participating in
decision-making throughout the therapeutic process.
Deep Breathing
The client was introduced to diaphragmatic breathing to manage acute physiological
symptoms of stress. This practice was grounded in evidence from psychophysiological research,
which shows that activating the parasympathetic nervous system leads to reductions in heart rate,
blood pressure, and muscular tension. The client learned to place one hand on her chest and one
 12

on her abdomen to ensure correct technique, ensuring that only the lower hand moved during
inhalation.
Breathing exercises were practiced at the beginning and end of each meeting, as well as
during emotionally charged discussions. She was taught a 4-4-6 breathing pattern: inhale for four
seconds, hold for four seconds, and exhale for six seconds. This variation prolonged exhalation,
promoting greater vagal tone and relaxation. Visualization was incorporated, such as imagining
exhaling stress as dark smoke or inhaling calm as light, to enhance the experience. Verbal
prompts and soft instrumental music were sometimes used to create a calming atmosphere.
A daily breathing log helped track frequency and effects of the practice, encouraging
accountability and self-awareness. Over time, the client independently applied this technique
during moments of emotional overwhelm, especially in school settings and during interpersonal
tension at home. She reported increased ability to control panic symptoms such as shortness of
breath, racing heart, and dizziness.
The continued use of this technique strengthened the client’s internal coping resources. It
gave her a reliable tool that she could access anywhere and anytime, reinforcing the belief that
she had control over her physiological responses. This sense of mastery further improved her
emotional regulation, contributed to a reduction in avoidance behavior, and enhanced her
readiness to use other therapeutic skills.
Progressive Muscle Relaxation (PMR)
Progressive Muscle Relaxation was introduced as a systematic strategy to reduce somatic
symptoms and emotional arousal. Each practice began with a calm environment where external
disturbances were minimized. The client followed a script that guided her through tightening and
relaxing specific muscle groups sequentially—starting from the feet, moving to the calves,
thighs, abdomen, chest, arms, and ending with the facial muscles. She was instructed to tense
each group for five seconds and then release for fifteen seconds, focusing on the change in
sensation.
Verbal cues encouraged mindfulness, such as "notice the warmth" or "feel the difference"
between tension and relaxation. Initially, sessions were guided live, and later audio recordings
were given for home practice. The client was encouraged to journal post-relaxation experiences,
identifying physical sensations, emotional states, and any arising thoughts. This documentation
highlighted trends and gave insight into the emotional triggers of physical discomfort.
 13

Regular use of PMR helped alleviate symptoms such as tightness in the shoulders, headaches,
and fatigue, which had previously contributed to her irritability and lack of motivation. The
technique also became an evening routine to prepare her body for restful sleep. By linking mind
and body experiences, PMR reinforced the connection between mental calmness and physical
relaxation, which improved her body image and awareness.
PMR also played a crucial role in increasing emotional regulation. The client reported
that mastering the rhythm of tensing and releasing gave her a tangible sense of control and calm.
This sense of agency translated into other areas of life, such as handling school stress and
interpersonal conflict more calmly. The process of bodily attunement cultivated through PMR
was a key factor in sustaining therapeutic gains.
Sleep Hygiene
To address chronic sleep disturbances, an individualized sleep hygiene protocol was
implemented. A thorough exploration of the client’s bedtime routine revealed inconsistent sleep-
wake times, excessive pre-bed screen use, and anxiety-driven rumination. Education began with
teaching the role of melatonin, circadian rhythms, and the impact of light exposure on sleep
regulation. The client was guided to create a bedtime ritual that cued her body for rest, including
dim lighting, calming music, and reading brief positive material.
Stimulants such as caffeine and sugar were monitored, especially in the afternoon and
evening. Physical activity was scheduled earlier in the day to avoid arousal close to bedtime. The
bedroom was optimized for rest—clean bedding, dim lights, minimal noise, and temperature
regulation were ensured. Blue light filters were installed on devices, and a digital cut-off time of
one hour before bed was established. Aromatherapy with lavender oil was introduced as an
optional calming aid.
She was encouraged to maintain a fixed wake-up time, even on weekends, to reset her
internal clock. Sleep logs were used not only to record time but also to track mood and energy
levels the next day. Patterns showed that quality sleep positively influenced her ability to focus,
manage emotions, and tolerate frustration. Sleep resistance behaviors, such as delaying bedtime
or sleeping in after nightmares, were addressed using gentle behavioral prompts and cognitive
restructuring.
Over time, improved sleep was correlated with higher daytime alertness, more consistent
school attendance, and better engagement in therapy. The client expressed pride in independently
 14

managing her sleep routine, which fostered autonomy and increased adherence to self-care.
Improved rest enhanced all aspects of functioning, including mood stability, cognitive flexibility,
and physical vitality.
 15

Case No.2
Intellectual Disability Disorder
Bio Data
Name D.R
Age 11
Gender Male
No. Of Sibling 3
Birth Order 2nd
Informant Mother
Source and Reason for Referral
The client’s parents brought him to the institute and he was referred to a trainee
counselling psychologist by his school teacher. The reason of referral as such having problems
with writing, Being socially immature, impaired motor skills, poor memory and impaired speech
and language.
Presenting Complaints
Table :Presenting Complaints by Mother
‫دورانیہ‬ ‫مسائل‬
5 ‫سال‬ ‫اپنی عمر سے بہت پیچھے ہے‬
2 ‫سال‬ ‫لکھنے میں مشکل ہوتی ہے پنسل صحیح سے نہیں پکڑپاتا‬
3‫سال‬ ‫صحیح سےچل نہیں سکتا‬
3‫سال‬ ‫خود کو سنبھال نہیں سکتا‬

2‫سال‬ ‫ضد کرتا ہےاور بات نہیں مانتا‬

‫حالیہ‬ ‫غصہ کرتا ہے اور چیزیں پھینکتا ہے‬

‫حالیہ‬ ‫دوسروں سے میل جول نہیں رکھتا‬

Initial Observations
The client entered the counselling room with his mother and appeared hesitant to separate
from her. He tightly held her hand and remained close to her throughout the session. His eyes
moved around the room, but he showed little spontaneous interest in toys or play materials
 16

placed nearby. He avoided eye contact with the therapist and remained mostly silent during the
first few minutes.
He responded only after repeated encouragement from his mother, and even then, his
answers were brief and unclear. When asked to perform simple activities like picking up blocks
or drawing, he seemed confused and showed poor coordination. His grip on the pencil was weak,
and he quickly gave up when he couldn’t complete the task. At one point, he threw a toy aside,
showing frustration.
He seemed more comfortable when his mother talked for him or directed his attention.
No signs of aggression were noted during the session, but he displayed low energy, emotional
flatness, and minimal social engagement. Overall, his behavior during the first meeting
suggested emotional dependence, difficulty adjusting to unfamiliar settings, and poor frustration
tolerance.
History of Present Illness
The client was brought to the clinic due to academic difficulties, poor speech
development, motor delays, and behavioral concerns such as aggression, stubbornness, and
difficulty socializing with peers. According to the mother, the child was born via cesarean
section with low birth weight and remained physically weak during early childhood. He
experienced significant developmental delays, including sitting at 13 months, walking at 2 years,
and forming complete sentences at 5 years. Speech was unclear, and the client struggled with
both expressive and receptive communication.
Additionally, the child suffered from medical issues in early life, including difficulty
swallowing due to enlarged tonsils, which affected his physical strength and feeding patterns. He
also has a visible eyelid droop and reduced vision, although no formal diagnosis for a visual
impairment was provided.
The mother reported that the client has always had difficulty adapting to social settings
and displays tantrum-like behaviors when his needs are not met. He shows poor attention span,
limited frustration tolerance, and difficulty understanding and following instructions. His self-
care abilities, including dressing and eating independently, are below age expectations.
These concerns were first noticed in the preschool years and became more apparent as
academic demands increased. His teacher noted that he struggles to retain information, follow
 17

classroom routines, and engage with peers, leading to a recommendation for psychological
evaluation.

Birth Order
The client is the second of three siblings. Positioned between an elder brother and a
younger sister, he has experienced both the role of being cared for and caring for others. Unlike
the eldest sibling, who often assumes responsibility, and the youngest, who tends to receive more
leniency and attention, the client’s middle-child position may have contributed to feelings of
being overlooked. Despite this, his siblings are described as emotionally supportive and friendly,
which has provided a stable foundation for his development. However, due to his intellectual and
developmental challenges, he remains dependent on others for daily functioning. His position in
the family has shaped a temperament marked by emotional sensitivity, occasional frustration,
and a need for reassurance, especially when faced with tasks that exceed his abilities. These
patterns, combined with his limited social engagement, reflect his internal struggle to find a
secure role within both family and peer systems.
Childhood
The client’s childhood was described as emotionally stable but developmentally delayed.
He was raised in a middle-class, nuclear family where his basic needs were met with care and
attention. Both parents were involved in his upbringing, and the home environment was
generally warm and supportive. Despite receiving love and attention from family members, the
client’s early years were marked by significant health concerns, including birth complications
and early physical weakness, which affected his developmental progress.
From an early age, the client appeared quiet, less responsive, and emotionally dependent
compared to peers. His mother reported that he rarely engaged in outdoor or group play and
often preferred staying close to familiar adults. He struggled with motor coordination and speech
delays, which further limited his social interaction and peer bonding. Behavioral issues such as
stubbornness, irritability, and emotional outbursts began to appear in early childhood, especially
when his needs were not understood or fulfilled.
Although no specific trauma was reported during childhood, his emotional sensitivity and
slow developmental pace made him more vulnerable to frustration and social withdrawal. These
 18

early difficulties shaped a temperament that is still evident in his current emotional and
behavioral functioning. His dependence on caregivers and limited adaptive skills continue to
influence his adjustment in academic and social environments.

Premorbid Personality
The client's premorbid personality, as described by his mother, reflected traits of
emotional sensitivity, quietness, and low responsiveness. Even before the clear emergence of
developmental concerns, he was noted to be less socially active and more dependent on familiar
adults for comfort and support. He preferred solitary activities and showed limited interest in
peer interactions or group play, often avoiding social situations that required verbal or physical
engagement.
He demonstrated a low frustration tolerance and would become easily irritable or
emotionally reactive when faced with unfamiliar tasks or unmet needs. Although he did not
exhibit overtly aggressive behavior, mild oppositional tendencies such as refusing instructions or
expressing anger by throwing objects were reported. These behaviors appeared more related to
communication barriers and emotional frustration rather than deliberate defiance.
Overall, his premorbid temperament was characterized by emotional withdrawal,
dependency, and limited adaptability to new environments. These traits were present prior to the
full manifestation of his intellectual and developmental impairments, suggesting a predisposition
toward social and emotional underdevelopment. His personality style made him more reliant on
caregivers and less equipped to cope with external demands, further complicating his academic
and social adjustment.
History of Family Psychiatric/Medical Illness
There is no reported history of psychiatric illness within the client’s immediate or
extended family. Both parents are reported to be in good psychological and physical health, and
no instances of mental disorders, developmental delays, or substance abuse were noted among
close relatives.
In terms of medical history, the client’s mother reported complications during pregnancy and
delivery, which were medically managed. However, no chronic or hereditary physical illnesses
such as epilepsy, diabetes, cardiovascular disease, or neurological conditions have been observed
in the family.
 19

Overall, the family background appears to be medically and psychiatrically stable, with
no known familial patterns of illness that might directly contribute to the client’s current
psychological or developmental concerns
Temperament and Early Behavior
According to the client's mother, the child has always been quiet and less responsive
compared to peers. He showed signs of emotional sensitivity and low frustration tolerance from
an early age. His social engagement was limited, and he often avoided group play. Mild
aggressive behaviors, such as hitting or shouting when frustrated, were reported, especially when
his needs were not met or when seeking attention. These traits have remained relatively
consistent over time.
Assessment
The client was assessed across multiple domains to obtain a comprehensive understanding of his
cognitive, developmental, and behavioral functioning. A combination of structured and semi-
structured methods was used to gather clinically relevant data. The assessment process involved
the following techniques:
 Mental Status Examination
 Clinical Interview
 DSM-5 Diagnostic Criteria for Intellectual Disability
 The Portage Guide to Early Education (PGEE)
These techniques collectively provided insight into the client’s intellectual capacity, adaptive
functioning, developmental delays, and behavioral characteristics, which guided both diagnostic
formulation and management planning.
Mental Status Examination
 Appearance: The client appeared physically small for his age, with fair hygiene and
appropriately dressed. A drooping eyelid limited his ability to fully open one eye.
 Behavior and Psychomotor Activity: He was generally restless, struggled to remain
seated, and frequently moved his hands and legs. He complied with instructions but
displayed hyperactivity and distractibility.
 Speech: His speech was low in tone, poorly articulated, and often unclear, requiring
repetition. He was cooperative and repeated words when prompted.
 20

 Mood and Affect: The client displayed a neutral to mildly positive mood, often smiling.
Affect was appropriate but somewhat restricted.
 Thought Process: Thought processes were goal-directed but limited in complexity,
consistent with his cognitive level. He managed simple tasks but had difficulty with
multi-step instructions.
 Thought Content: No delusional thinking, obsessions, or preoccupations were observed.
No suicidal or homicidal ideation was reported.
 Perception: No hallucinations, illusions, or perceptual disturbances were evident.
 Cognition: The client was oriented to person, place, and time. He demonstrated basic
awareness of his surroundings but showed significant cognitive delays for his age.
 Memory: Immediate recall was intact for simple information, but working memory and
retention of new material appeared weak.
 Insight: Insight into his difficulties was limited and appropriate to his developmental
level.
 Judgment: Judgment was immature and impaired, requiring external prompting for
decision-making.
Clinical Interview
A detailed clinical interview was conducted with the client’s mother to gather
comprehensive information about his developmental, educational, medical, and psychosocial
history. The mother reported that her pregnancy was complicated by illness, and delivery
occurred via C-section due to medical complications. At birth, the client weighed approximately
3–4 pounds and had enlarged tonsils, which significantly affected his ability to suck and
swallow. As a result, he was unable to feed properly for the first year of life, leading to
considerable weakness and delayed attainment of developmental milestones.
The mother described significant delays in his early developmental achievements. He
began neck holding at 6 months, sitting independently at 13 months, standing at 16 months, and
walking at 2 years. Crawling was absent altogether. His first spoken word appeared at 25
months, and he could only form complete sentences around the age of five. Bladder control was
attained at 4 years of age, and he still requires assistance with tasks such as bathing and other
daily living activities.
 21

Regarding his current functioning, the mother reported persistent difficulties in fine
motor tasks such as gripping a pencil and writing. She noted that despite being enrolled in
school, his academic progress has been slow, and he remains significantly behind peers in
reading, writing, and comprehension. Teachers have described him as socially withdrawn, easily
distracted, and hesitant to engage in classroom activities.
Behaviorally, the mother reported that he is generally quiet but becomes irritable and
stubborn when his demands are not met or when his routines are disrupted. She mentioned
instances of aggressive outbursts, such as shouting or throwing objects, particularly when
interacting with siblings or when seeking attention. His social interactions are limited, and he
tends to avoid group play, preferring solitary activities like observing his surroundings or
coloring.
Emotionally, the mother expressed concern about his lack of confidence and limited
communication skills. She also noted that he becomes easily frustrated when faced with
challenging tasks. Despite these difficulties, she described him as affectionate with family
members and responsive to praise, indicating the potential for positive reinforcement strategies.
This interview provided essential insights into the client’s developmental trajectory, behavioral
patterns, and family dynamics, which helped in understanding his intellectual and adaptive
deficits and informed the selection of appropriate assessment tools and therapeutic interventions.
DSM-V Criteria Table
DSM-V criteria Child’s Symptoms Present/Absent
Deficits in intellectual functions, such as The client has deficits in hisPresent
reasoning, problem solving, planning, abstract executive functioning and it has
thinking, judgment, academic learning, and been confirmed by assessments.
learning from experience, confirmed by both
clinical assessment and individualized,
standardized
intelligence testing.
eficits in adaptive functioning that result inThe client couldn’t meet thePresent
failure to meet developmental anddevelopmental standards as He
sociocultural standards for personalscored lower in portage guide for
independence and social responsibility.early education.
 22

Without ongoing support, the adaptive deficits

limit functioning in one or more activities of
daily life,
such as communication, social participation,
and independent living, across multiple
environments, such as home,
school, work, and community.
Onset of intellectual and The client’s problem also began inPresent
adaptive deficits during the developmentalearly developmental period
period.

Portage Guide to Early Education

The Portage Guide to Early Education (PGEE) was developed to serve as an aid to
teachers, parents or others who need to assess the child’s behavior and plan realistic curriculum
goals that lead to additional skills. There are five goals of PGEE; to enhance a developmental
approach to teaching, to concern it with several areas of development including cognitive,
language, motor, socialization, and self-help skills, to provide a method of recording the existing
skills and recording skills learned in the intervention period, to provide suggestions on how new
skills could be taught (Bluma, Shearer, Froham & Hilliard, 1976).
In the current case, the revised edition of PGEE was administered to assess the client’s
developmental progress. The purpose of using this tool was to evaluate functioning in key areas
such as socialization, self-help, motor, cognitive, and language development. The objective was
to identify skill delays, determine developmental age levels, and guide the formation of an
Individualized Education Plan (IEP). Each assessment session lasted approximately 45 minutes
and involved both direct interaction with the client and information from the mother. Materials
such as color pencils, activity sheets, and objects for motor testing were utilized. The results
revealed significant discrepancies between the client’s developmental and chronological age,
indicating the need for targeted therapeutic intervention.
Results
Chronological age: 11 years
 23

Table 4.5
Areas Developmental Age Developmental age
(months) (Years)
Socialization 50.5months 4years 2month
Self Help 65.5months 5years 5months
Language 57.6 months 4years 9months
Cognitive 59.2months 4years11months
Motor 58.6months 4years 10months

Qualitative Analysis
The client's developmental functioning shows significant delays across all domains. In
socialization, his developmental age is 4 years and 2 months, indicating a gap of approximately
7 years from his chronological age of 11 years. In self-help skills, his age equivalent is 5 years
and 5 months, with a discrepancy of about 6.6 years. Similarly, he functions at 4 years 9 months
in language, 4 years 11 months in cognitive, and 4 years 10 months in motor domains — each
showing a delay of 5.5 to 6 years. Overall, the Portage Guide results reflect that the client’s
adaptive functioning is significantly below his expected developmental level, requiring
structured support.
Diagnosis
Based on clinical interviews, behavioral observations, and standardized assessments, the client
meets the diagnostic criteria for:
318.0 (F71) Moderate Intellectual Disability
Case Formulation
Predisposing Factors
The client’s developmental difficulties are rooted in multiple biological and psychosocial
vulnerabilities. He was born with low birth weight (3–4 pounds) and experienced feeding
difficulties due to congenital tonsillar enlargement, which significantly compromised his
nutritional intake during infancy. As a result, he remained physically weak and failed to meet
early developmental milestones within the expected time frame. Maternal illness during
pregnancy is an important contributing factor, as prenatal infections and health complications are
known to negatively affect neurodevelopment. Furthermore, the absence of early medical
intervention for his feeding issues and the delayed recognition of his developmental challenges
 24

may have exacerbated his cognitive delays. His limited exposure to structured play and reduced
engagement in stimulating activities during early childhood likely further restricted his cognitive
and adaptive skill development. These biological and environmental vulnerabilities created a
strong predisposition for the development of intellectual disability.
Precipitating Factors
The client’s difficulties became more prominent as academic and social demands increased,
particularly when he started school. His inability to grip a pencil, follow classroom instructions,
and retain new information led to repeated academic failures, which have been a source of
frustration for both him and his caregivers. These challenges triggered increased emotional
reactivity, including stubbornness, irritability, and occasional aggressive outbursts such as
throwing objects or shouting. Additionally, his social immaturity and inability to engage in age-
appropriate peer interactions have reinforced feelings of isolation and reduced his motivation to
participate in group activities. The growing gap between his abilities and environmental
expectations has acted as a key precipitating factor in intensifying his behavioral and emotional
difficulties.
Perpetuating Factors
Several factors continue to maintain the client’s current level of functioning. His high
dependence on caregivers for basic self-help tasks prevents him from developing independence,
while his low frustration tolerance and avoidance of challenging tasks reinforce a cycle of
underachievement. The absence of specialized educational interventions tailored to his
intellectual needs further perpetuates his academic struggles. Additionally, his limited
socialization and emotional withdrawal reduce opportunities for learning through peer modeling
and collaborative play. Inconsistent reinforcement of positive behaviors and the family’s reliance
on accommodating his demands rather than encouraging gradual independence may also
contribute to the maintenance of his difficulties.
Protective Factors
Despite significant challenges, the client has several strengths that enhance his potential for
improvement. He lives in a stable, nuclear family system where both parents are emotionally
available and actively involved in his upbringing. His mother demonstrates strong caregiving
skills, provides consistent emotional support, and has shown willingness to engage in
psychoeducation and implement behavioral strategies. The client has affectionate relationships
 25

with his siblings, who provide emotional comfort and cooperative interactions. Additionally, his
responsiveness to praise and simple reinforcers such as coloring and rewards suggests that
behavior modification techniques could be highly effective in promoting skill development. The
school staff’s cooperative attitude and their referral for psychological evaluation indicate that he
has access to external support systems willing to assist in his growth.
Diagnostic Formulation
The client is an 11-year-old male presenting with significant deficits in intellectual and adaptive
functioning, as evidenced by his performance on the Portage Guide to Early Education (PGEE),
which indicates developmental delays of approximately 5–7 years across multiple domains,
including cognitive, social, motor, and self-help skills. His clinical presentation—marked by
delayed milestones, poor academic performance, impaired motor coordination, unclear speech,
social withdrawal, low frustration tolerance, and emotional dependency—is consistent with
Moderate Intellectual Disability (318.0, F71) as per DSM-5 criteria. Biological vulnerabilities
(low birth weight, maternal illness, congenital tonsillar enlargement), early developmental
delays, and limited access to early medical and educational interventions have contributed to his
current condition. However, the presence of a supportive family, positive responsiveness to
reinforcement, and access to cooperative school resources make his prognosis favorable,
provided that he receives structured, individualized educational and therapeutic interventions
focused on improving cognitive, adaptive, and social functioning.
Counselling Process
The counselling process for this 11-year-old client with Moderate Intellectual Disability (F71)
was comprehensive and multi-layered, focusing on behavioral modification, skill development,
emotional regulation, and family empowerment. The plan was implemented over multiple
sessions, adapting strategies to the child’s cognitive level and family context.

Rapport Building
Rapport building is foundational in therapeutic settings and is particularly critical when working
with children with intellectual disabilities. It refers to the therapist's ability to create an
atmosphere of trust, acceptance, and mutual understanding, which fosters emotional safety for
both the client and caregiver (Zakaria & Musta'amal, 2014). In cases where children exhibit
limited language abilities, attention difficulties, or emotional sensitivity, rapport becomes the
 26

cornerstone of therapeutic success, as it directly impacts assessment reliability and intervention

outcomes (Rogers, 1957).
In this case, rapport was developed simultaneously with the child and his mother using a child-
centered and family-sensitive approach. The therapist engaged the mother with empathy, active
listening, and unconditional positive regard—core principles of client-centered therapy (Rogers,
1959). Her initial concerns and emotional responses were validated using simplified, jargon-free
language, allowing her to feel understood and respected. This method has been shown to reduce
parental anxiety and increase cooperation during therapy (Brookman-Frazee et al., 2009).
With the child, the therapist employed a developmentally appropriate approach using non-verbal
communication, soft vocal tones, smiling, and gentle praise to initiate engagement. Activities
such as coloring, simple naming tasks, and storytelling were used to create a relaxed and
enjoyable environment (Guralnick, 2011). These low-demand, play-based tasks served as the
initial foundation for trust-building, helping the child feel safe and understood.
Over time, rapport was further strengthened through consistency and structure. Sessions
followed a predictable pattern, beginning with familiar greetings and preferred tasks, creating a
routine that offered emotional safety. Positive reinforcement techniques—including praise,
stickers, and access to enjoyable activities—were used to encourage cooperation and reduce
avoidance. These strategies aligned with behaviorist principles, emphasizing that consistent
reinforcement fosters the repetition of desired behaviors (Skinner, 1953). The child began
displaying signs of emotional comfort, such as eye contact, initiating interaction, and showing
enthusiasm during sessions.
Parental involvement was intentionally woven into the rapport-building process. The mother was
occasionally invited to participate in structured activities, serving dual purposes: increasing the
child's comfort and modeling effective interaction strategies for the caregiver. This approach is
consistent with ecological models of development, which highlight the central role of family
systems in promoting child progress (Bronfenbrenner, 1979). Home-based tasks, such as
practicing praise and encouraging simple behaviors, were assigned to enhance generalization and
reinforce therapeutic gains at home.
As rapport deepened, the therapist observed noticeable shifts in the child's emotional responses.
Initially withdrawn and passive, he gradually displayed curiosity, joy, and initiative. These
changes, though subtle, are significant in children with intellectual disabilities, where emotional
 27

expression is often limited. Likewise, the mother reported increased confidence in the therapeutic
process and expressed hopefulness about her child's potential.
Finally, rapport was treated not as a one-time achievement but as a continuous, evolving process.
The therapist remained attuned to the child's mood and needs in each session, adapting activities
when signs of frustration or disengagement arose. Techniques such as humor, shared play, and
gentle encouragement were used to re-engage the child. As Norcross and Lambert (2011) note,
the quality of the therapeutic relationship is among the strongest predictors of positive outcomes.
In this case, sustained rapport laid the groundwork for effective behavioral intervention and
emotional growth.
Psychoeducation
Psychoeducation involves equipping individuals and families with relevant knowledge about a
condition to reduce anxiety, increase insight, and facilitate collaborative care. It includes
information on diagnosis, causes, treatment options, and coping strategies, helping families
understand the nature of the problem and their role in managing it (Psycho-Educational
Counseling Services, 2002). First introduced in the 1950s by Anderson et al., the concept has
since become a standard component of family-centered therapy.
In the present case, psychoeducation was primarily provided to the mother to help her understand
the nature and implications of her child’s intellectual disability. She was informed that
intellectual disability is characterized by significant limitations in both intellectual functioning
(e.g., reasoning, learning) and adaptive behavior (e.g., daily living skills). The therapist
explained that the condition originates before age 18 and often includes delayed developmental
milestones. These explanations were simplified to match the caregiver’s understanding, ensuring
clarity without overwhelming her.
The therapist highlighted how behavior modification strategies—especially structured
reinforcement—can help the child gradually acquire social and functional skills. Emphasis was
placed on practical involvement, such as using praise, consistent routines, and home
reinforcement of tasks learned in therapy. This collaborative approach helped the mother feel
empowered, reducing her distress and enhancing her engagement in the therapeutic process.
Throughout the sessions, the therapist consistently reassured and supported the mother,
encouraging her to ask questions and express concerns. Her understanding of the condition
improved, and she reported feeling more hopeful and emotionally prepared to support her child's
 28

development. Psychoeducation also helped dispel guilt and self-blame, which are commonly
reported among parents of children with developmental disabilities.
Positive Reinforcement
Positive reinforcement involves strengthening a behavior by following it with a rewarding
stimulus, thereby increasing the likelihood of its recurrence (Miltenberger, 2012). In this case,
reinforcement was essential to facilitate the child's engagement, compliance, and acquisition of
new skills. Initially, a continuous reinforcement schedule was used, where every correct
behavior—such as sitting properly or responding correctly—was immediately followed by a
reward. This technique is highly effective in the early stages of learning (Skinner, 1953).
As the child’s behavior stabilized, an intermittent reinforcement schedule (fixed ratio) was
implemented. This shift reduced the child’s dependency on constant rewards and encouraged
more independent behavior. Reinforcers were carefully selected based on the child’s personal
preferences, such as watching clips of Doraemon or Tom and Jerry, ensuring motivation
remained high. This approach aligns with the principle of functional reinforcement, which
emphasizes tailoring rewards to individual interests (Odom et al., 2003).
Reinforcement was not limited to correcting behavior; it also enhanced emotional participation.
The child began to anticipate sessions with excitement, maintained better attention, and showed
fewer signs of resistance. Reinforcement was used to shape target behaviors such as correct
responding, joint attention, and participation in guided tasks.
Importantly, the mother was also trained in basic reinforcement strategies during sessions. She
learned how to apply praise and token rewards for everyday accomplishments, such as
completing a simple task or following a command. Parental involvement in reinforcement
increases the generalization of therapeutic gains and strengthens home routines (Ingersoll &
Dvortcsak, 2006). The therapist also advised periodic updates in reinforcers, suggesting
alternatives like sticker charts or short tablet time if cartoon clips became less motivating
(Vollmer & Northup, 1996).
Thus, positive reinforcement functioned as both a motivational tool and a behavioral strategy,
effectively supporting the child's developmental goals while creating an enjoyable and structured
therapeutic environment.
Prompting and Fading
 29

Prompting refers to the use of cues or assistance to increase the likelihood that a desired
behavior will occur in the correct context. In this case, both verbal and physical prompts were
employed to help the child learn basic developmental tasks. For example, while engaging in a
drawing activity, the therapist offered verbal guidance (“Draw a straight line now”) along with
light physical assistance to guide the child’s hand. These are known as response prompts, which
include verbal cues, gestures, modeling, or physical guidance (Miltenberger, 2012).
Since the child initially struggled to follow verbal instructions alone, physical prompting was
critical in bridging the gap between instruction and execution. Once the behavior became more
consistent, the therapist gradually reduced the level of prompting—a process known as fading.
Fading involves the systematic withdrawal of prompts to transfer control of the behavior from
the prompt to the natural discriminative stimulus (Miltenberger, 2012). For example, once the
child began drawing lines correctly with partial assistance, the therapist reduced physical contact
and shifted to verbal prompts only. Eventually, these too were faded, leading to independent task
performance.
This strategy prevented prompt dependency and encouraged autonomy, ensuring that learned
behaviors could generalize beyond the therapy setting. Prompting and fading were seamlessly
integrated into daily therapeutic routines and proved particularly effective in teaching motor
tasks, communication attempts, and sitting tolerance. These methods enabled the child to build
confidence and gradually internalize the skills needed for further developmental progress.
 30

Case No.3
Substance Abuse Disorder
Bio Data
Name A.J
Age 27
Gender Male
Marital Status Married
Education B.S complete
No. of Siblings 6
Birth Order First born
Informant Client himself
Reason of Referral
The client was brought to the hospital by his father, who was deeply concerned about his well-
being. The client himself showed a strong desire to break free from his addiction and rebuild his
life. He shared that his family has always stood by him with love and support, and he believes
that recovery is the key to living a happy, peaceful, and normal life again.
Presenting Complaints
Duration Complaints

3 years Persistent sensation of heart racing and discomfort

3 years Constant feelings of restlessness

3 years Recurrent episodes of anxiety and panic

3 years General physical uneasiness and bodily discomfort

3 years Frequent irritability and short temper

History of Present Illness
The client reported that his drug use began approximately three years ago at the age of
24. Initially, he started smoking cigarettes casually with his friends, which gradually progressed
into more serious substance use. With time, under peer influence, he began using heroin. At first,
it was experimental and occasional, but it soon became a regular part of his routine. The client
mentioned that he never anticipated developing a dependency, but as the usage increased, so did
the negative impact on his physical health, emotional state, and daily functioning.
 31

Over time, the client began to exhibit significant changes in mood and behavior. He
reported experiencing persistent restlessness, physical discomfort, and increased irritability. His
family began noticing behavioral changes such as frequent mood swings, social withdrawal, and
reduced engagement in family matters. These changes became a source of concern for his family,
especially his father, who eventually insisted that he seek treatment.
The client admitted that his addiction strained his relationship with his parents, siblings,
and wife. Though his family remained emotionally supportive, he could sense a growing distance
and disappointment, especially from his father. He also reported feelings of guilt, low self-worth,
and helplessness. He mentioned frequent episodes of anxiety and restlessness, especially when
he attempted to reduce or stop heroin use on his own. These episodes included symptoms such as
sweating, tremors, headaches, sleep disturbances, and low mood, which are consistent with
withdrawal.
His sleep patterns were also severely disturbed. He had trouble falling asleep and would
wake up multiple times during the night. He noted that his appetite decreased significantly
during this period. As the symptoms intensified, his ability to function at work declined,
ultimately leading to the loss of his job. He acknowledged that a large portion of his salary—
approximately 15k monthly—was spent on purchasing drugs.
The turning point came when his family, especially his father, strongly urged him to seek
professional help. Recognizing the toll addiction had taken on his health, relationships, and
overall life, client agreed to be admitted to hospital. He expressed a genuine desire to overcome
his addiction and rebuild his life. Currently, he is in the withdrawal phase of recovery and is
receiving medical and psychological treatment aimed at relapse prevention and emotional
stabilization.
Birth Order
The client is the eldest among his six siblings. Being the first-born, he shared a close
bond with both of his parents during childhood and carried a sense of responsibility within the
household. He reported that his parents never showed favoritism among the siblings and treated
each child with equal affection. As the eldest, he often acted as a role model for his younger
brothers and sisters.
He mentioned that he never felt neglected or replaced by the birth of younger siblings,
and his position in the family structure remained stable throughout his upbringing. His family
 32

viewed him as mature, responsible, and capable of handling difficult situations. However, the
client shared that over time, especially after developing an addiction, he began to feel that he had
failed in meeting the expectations associated with being the eldest child.
This perception of letting down his family added to his emotional distress and may have
contributed to his feelings of guilt and low self-esteem. During the recovery phase, he often
expresses a desire to regain his family’s trust and return to the supportive and respected role he
once had as the first-born child.
Childhood
Client described his childhood as emotionally secure and generally pleasant. He was
raised in a middle-class, joint family system in Sialkot, where the home environment was
supportive and friendly. His parents were attentive to his emotional and physical needs, and he
shared a particularly close bond with his mother. As the eldest of six siblings, he often took on
responsibilities at home, though he stated this was neither forced upon him nor burdensome.
He was a cheerful, active, and well-mannered child who enjoyed participating in family
activities. While he maintained friendly relationships with peers, he preferred familiar
environments and had a small circle of close friends. He adjusted well both at home and school,
with no significant behavioral or psychological concerns reported. His developmental milestones
were achieved within the normal age range, and he had no major physical illnesses or learning
delays. He performed reasonably well academically and was involved in co-curricular activities,
reflecting balanced personal and educational growth.
Although no traumatic events were reported, his emotionally sensitive and reserved nature may
have contributed to internalizing stress, which could be relevant in understanding his later
vulnerability to emotional distress and addiction in adulthood.
Educational History
Client began his formal education at a private school in Sialkot, where he was described as a
cooperative and well-behaved student. Although not among the top performers, he consistently
maintained average grades and was regarded as sincere in his academic efforts. His teachers
often praised his respectful behavior and willingness to participate in classroom discussions,
though he showed limited interest in taking initiative or leadership roles.
He completed both his matriculation and intermediate education without any significant
academic difficulties. Later, he moved to Islamabad to pursue higher education and successfully
 33

completed his B.S degree. During his university years, he remained academically stable, but he
reported that his motivation began to decline toward the end of his studies. He attributed this to
growing peer distractions and a lack of clear future goals, though he managed to graduate
without delays.
Client mentioned that while his overall academic experience was smooth, he never actively
sought help when facing challenges, believing them to be manageable on his own. No formal
psychological or academic counseling was sought during his student life. His educational
journey was largely unremarkable until his involvement in substance use began post-graduation.
Premorbid Personality
Before the onset of substance use, the client was generally described as responsible,
emotionally balanced, and well-adjusted. He fulfilled his daily responsibilities and maintained
positive relationships with both family and peers. As the eldest sibling, he took his role seriously
and was considered dependable by those around him. He preferred structure and routine and was
not known to engage in impulsive behavior.
Despite appearing emotionally stable, the client had a tendency to internalize stress rather
than express it openly. He often avoided discussing personal difficulties and managed emotional
discomfort on his own. This long-standing pattern of emotional suppression and self-reliance
may have contributed to his vulnerability during periods of psychological distress, particularly
leading up to his substance use.
Marital History
The client is married and has one son. He reported that the marriage was arranged and
generally stable, with no major conflicts prior to the onset of his addiction. He described his wife
as supportive and understanding, especially during the treatment phase. Although they
experienced occasional disagreements, these were mostly related to his drug use and its impact
on his behavior and responsibilities.
The client acknowledged that his addiction placed strain on the marital relationship,
leading to emotional distance and reduced communication at times. However, he emphasized
that his wife remained emotionally present and encouraged him to seek treatment. He expressed
a strong desire to rebuild the trust and connection within the marriage as part of his recovery
process.
 34

Despite the challenges, the client stated that there was no discussion of separation or
divorce. He viewed his wife’s support as a significant factor in his motivation to recover. He also
mentioned feeling emotionally attached to his son and reported missing him deeply during his
stay in the rehabilitation center, which further strengthened his commitment to treatment.
Occupational History
After completing his B.S degree, the client began working in a private company where he
initially reported job satisfaction and a stable routine. He performed his duties responsibly and
maintained positive relationships with colleagues and supervisors. He considered the job a good
opportunity for professional growth and was able to manage his work-life balance effectively
during the early phase of employment.
However, after the onset of substance use, the client’s work performance began to
decline. He admitted that a significant portion of his monthly income—up to 15k was spent on
drugs, which led to financial strain and reduced productivity. His attendance and focus at work
deteriorated over time, ultimately resulting in job loss. The client recognized that his addiction
directly affected his ability to maintain employment and expressed regret over the missed
opportunities due to his drug use.
History of Family Psychiatric/Medical Illness
The client reported no known history of psychiatric illness in his immediate or extended
family. He stated that none of his family members had been formally diagnosed with a mental
health disorder or received psychological treatment. Emotional support within the family has
generally been strong, and no history of behavioral or substance-related problems was reported
among his siblings or parents.
In terms of medical history, the client mentioned that his parents and siblings are in
generally good health, with no chronic or hereditary physical illnesses disclosed. He did not
identify any genetic or medical factors that may have contributed to his current condition. The
absence of psychiatric or medical illness in the family suggests that the client's issues are more
likely related to environmental, social, and personal factors rather than hereditary predisposition.
Assessment
The assessment was carried out in multiple dimensions to obtain a comprehensive
understanding of the client's psychological, emotional, and behavioral functioning. The
following techniques were administered:
 35

 Behavioral Observation
 Clinical Interview
 Mental Status Examination
 Rotter Incomplete Sentences Blank (RISB)
 Drug Abuse Screening Test (DAST)
Behavioral Observation
The client appeared for the session with appropriate personal hygiene and was dressed
neatly. His posture was slightly slouched, and his overall physical presentation suggested mild
fatigue. During the interaction, he maintained intermittent eye contact and showed signs of
emotional discomfort when sensitive topics such as his substance use and family issues were
discussed.
His speech was clear and coherent, though his tone occasionally became low and hesitant
when expressing feelings of guilt and regret. The client’s mood appeared subdued, and his affect
was restricted but appropriate to the context. Observable signs of restlessness were present,
including frequent leg movements and shifting in his seat, indicating underlying anxiety or
withdrawal discomfort.
He remained cooperative throughout the assessment process and showed a willingness to
engage. Despite moments of emotional withdrawal, he responded to questions with sincerity and
appeared motivated to change. His overall behavior reflected a mix of emotional distress, self-
awareness, and readiness for recovery.
Clinical Interview
A clinical interview was conducted to gather detailed information regarding the client’s
presenting complaints, psychosocial background, personal and family history, and motivation for
treatment. The client was cooperative throughout the process and responded to questions
appropriately. He demonstrated adequate insight into his condition and expressed a genuine
desire to recover from his substance use.
During the interview, the client shared that his drug use began around the age of 24,
initially through cigarettes and then progressing to heroin under peer influence. He
acknowledged that his addiction significantly impacted his emotional, social, and occupational
functioning. He openly discussed feelings of guilt, helplessness, and regret, particularly in
relation to his family and the breakdown of his routine life.
 36

The client identified family support—especially from his father and wife—as a major factor
motivating him to seek treatment. He expressed emotional pain over disappointing his loved ones
and a strong need to regain their trust. Despite current struggles with withdrawal symptoms, he
appeared motivated to rebuild his personal and professional life.
Mental Status Examination
The client was alert and oriented to time, place, and person. His level of consciousness
appeared normal, and he was able to engage meaningfully throughout the session. His grooming
and hygiene were appropriate, and he maintained a cooperative attitude during the interaction.
His mood was described as “low” and “anxious,” and his affect was constricted but congruent
with the content discussed. He exhibited signs of mild psychomotor agitation, such as fidgeting
and shifting in his seat. No formal thought disorder was observed; his thought processes were
logical and goal-directed, although at times slowed when reflecting on emotionally distressing
topics.
Perceptual disturbances such as hallucinations or delusions were not evident during the
interview. The client did not express any active suicidal or homicidal ideation but did report a
history of hopelessness and worthlessness during periods of withdrawal. His insight into his
condition was fair, and his judgment appeared intact, particularly regarding his decision to seek
treatment and his awareness of the consequences of continued drug use.
Memory and concentration were mildly impaired, likely due to emotional distress and
withdrawal-related discomfort. However, overall cognitive functioning appeared within the
normal range. The client demonstrated adequate motivation to participate in therapy and showed
an understanding of the treatment goals.
Rotter Incomplete Sentences Blank (RISB)
The Rotter Incomplete Sentences Blank is the most frequently used sentence completion
test of personality. A performance-based test, the RISB is used to screen for adjustment
problems, to facilitate test conceptualization and diagnosis, and to monitor treatment.
Quantitative Interpretation
The cut-off score in this test is 135. Above 135 scores, the clients show maladjustment.
 37

Code Response Point Scores

P1 3 2 6
P2 4 1 4
P3 2 0 0
C1 5 4 20
C2 11 5 55
C3 10 6 60
N 5 3 15
Total = 160
Qualitative Interpretation
The client’s responses reflected strong emotional conflict, guilt, and hopelessness.
Themes of self-blame, relationship strain, and fear of relapse were dominant. The overall pattern
indicates significant emotional disturbance and maladjustment requiring therapeutic intervention.
Drug Abuse Screening Test (DAST)
The drug abuse screening test (DAST) was designed to provide a brief instrument for
clinical screening and treatment evaluation research. The 28 self-report items tap various
consequences that are combined in a total DAST score.
Quantitative Interpretation
The client answered YES to 11 items and answered NO to 14 items, the total score of
client is 11 when being assessed through DAST which shows that the client has just a mere
sensitivity to drug abuse and the client do not have any substance abuse problem.
Qualitative Interpretation
On DAST the number of yes responses indicated over the past 12 months the client was
using the drug other than those required for medical reasons but the test shows that the client
does not have a problem with drug abuse the problem of abusing drug exists.
Diagnosis
On the basis of client’s history, presenting complaints, behavioral observation, clinical
interview, and results from formal assessments, a diagnosis has been made in accordance with
DSM-5 criteria. According to the DSM-5 classification, the client is suffering from:
Substance Abuse Disorder, Severe (F11.20)
 38

The client demonstrated a history of persistent heroin use, withdrawal symptoms, occupational
and interpersonal dysfunction, and psychological distress over a period of three years. Currently,
the client is in the early stages of recovery and is receiving treatment. His emotional insight,
motivation to change, and family support indicate potential for positive rehabilitation outcomes.
Case Formulation
Predisposing Factors
Client psychological vulnerabilities appear to stem from early environmental and
personality factors. As the eldest child in a joint family system, he was raised with a sense of
responsibility and high expectations. While his childhood was largely stable and emotionally
secure, his natural sensitivity and tendency to internalize emotions made him more prone to
emotional suppression. The absence of early help-seeking behaviors and a reliance on self-
management may have contributed to the buildup of unresolved stress. His personality reflected
a pattern of emotional restraint, self-blame, and avoidance of expressing vulnerability — which
likely increased his susceptibility to addiction as a maladaptive coping strategy during distress.
Precipitating Factors
The onset of client drug use began approximately three years ago and was largely
influenced by environmental and social stressors. Peer pressure played a significant role in
initiating substance use, beginning with casual smoking and escalating to heroin use. This
coincided with a period of growing uncertainty regarding his career goals and declining
motivation during the final stages of his university education. Additionally, emotional distress
linked to perceived personal failure, unmet expectations, and increasing inner tension may have
triggered the shift from occasional use to dependency. These immediate stressors acted as
catalysts for the development of psychological and physiological reliance on substances.
Perpetuating Factors
The client’s current condition continues to be maintained by both psychological and
behavioral patterns. His persistent feelings of guilt, low self-worth, and helplessness reinforce his
emotional distress and increase the risk of relapse. Avoidance of emotional expression, difficulty
in seeking support, and a tendency to isolate himself contribute to the maintenance of
psychological symptoms. Withdrawal symptoms such as restlessness, sleep disturbance, and
irritability further complicate recovery and reduce emotional stability. Additionally, strained
 39

family relationships and internalized shame continue to affect his confidence, reinforcing a cycle
of self-doubt and emotional suppression, which perpetuates the dependency framework.
Protective Factors
Despite these challenges, client possesses several strengths that serve as protective factors
in his recovery process. He has demonstrated clear insight into his condition and a strong desire
to rebuild his life. The emotional and practical support of his family — particularly his wife and
father — serves as a key motivational force in his treatment. His successful completion of a B.S.
degree and prior work experience reflect his capability and resilience. His willingness to engage
in therapy, participate in structured rehabilitation, and adopt new coping strategies show strong
potential for positive psychological change. The therapeutic relationship established during
counseling provides a secure space for continued emotional growth and relapse prevention.
Diagnostic Formulation
Based on the clinical interview, behavioral observation, test data (RISB and DAST), and
presenting complaints, client appears to be experiencing symptoms consistent with Substance
Use Disorder (Heroin Dependence), currently in the withdrawal and early recovery phase.
His condition is marked by a chronic pattern of compulsive drug use, emotional suppression,
physiological symptoms of withdrawal (e.g., restlessness, disturbed sleep, anxiety), and
functional impairments in social and occupational domains.
Cognitive features include distorted thought patterns such as guilt-based self-perception,
hopelessness, and an exaggerated fear of failure. Emotional numbing, avoidance of emotional
expression, and low tolerance for psychological discomfort further reinforce the addictive cycle.
While no formal psychiatric diagnosis was recorded in the past, the client’s symptoms reflect a
longstanding pattern of psychological dependence and maladaptive coping, rather than an
isolated or acute episode. Continuous therapy and structured relapse prevention strategies are
recommended for long-term recovery and emotional regulation.
Counselling process
Therapeutic Approach
Cognitive Behavioral Therapy (CBT) was selected as the foundational therapeutic approach due
to its proven effectiveness in addressing substance use, emotional dysregulation, and cognitive
distortions. CBT is structured, time-limited, and focuses on the dynamic relationship between
thoughts, feelings, and behaviors. For A.J., who presented with persistent guilt, low self-worth,
 40

and maladaptive coping patterns associated with drug use, CBT provided a structured framework
to work through these difficulties.
In therapy, the client was guided to identify automatic negative thoughts, particularly those
linked to self-blame (“I’ve failed my family”), helplessness (“I can’t recover”), and hopelessness
(“There’s no future for me”). Through cognitive restructuring, these beliefs were actively
challenged and replaced with more balanced alternatives. Behavioral strategies such as activity
scheduling, exposure to avoided situations, and self-monitoring were incorporated to interrupt
avoidance patterns and enhance motivation. The collaborative nature of CBT empowered the
client, giving him a sense of agency and responsibility in his recovery. Over time, he
demonstrated growing insight into his behavior and developed more adaptive coping strategies,
contributing to improved emotional regulation and reduced relapse risk.
Psychoeducation and Emotional Expression
Psychoeducation was a central part of the counselling process and was used to enhance the
client’s understanding of his psychological condition. The client was educated about the
physiological and psychological effects of drug abuse, the functioning of the brain's reward
system, and the mechanisms of craving and withdrawal. This included discussions on how
addiction develops, why cravings occur, and what environmental and emotional triggers can lead
to relapse. The purpose was to normalize his experiences, reduce shame, and increase his
motivation by helping him understand that addiction is a treatable condition—not a moral failure.
In parallel, the therapy process emphasized emotional expression, especially since the client
initially showed hesitation in discussing his internal experiences. His early responses were
marked by emotional suppression, short replies, and reluctance to admit distress. To address this,
the therapist employed consistent rapport-building strategies, including reflective listening,
empathy, and non-judgmental responses. As trust developed, the client gradually began to
verbalize deeper emotions, such as guilt for disappointing his family, sadness over job loss, and
fear of future relapse. These emotional breakthroughs were crucial for therapeutic progress, as
they allowed for the processing of unresolved emotional pain and helped the client reconnect
with his inner experiences in a healthier way.
Relaxation and Coping Techniques
To reduce the physiological symptoms of anxiety and restlessness common during the
withdrawal phase, a range of relaxation and self-regulation techniques were introduced. These
 41

methods helped the client manage emotional arousal and provided him with tools to cope with
cravings and stress without reverting to drug use.
 Progressive Muscle Relaxation (PMR): This technique involved teaching the client to
sequentially tense and relax major muscle groups. Initially unfamiliar with the method,
the client expressed curiosity and mild discomfort in the first session. However, after
practicing with guidance, he reported noticeable relief in muscular tension and
psychological discomfort. Continued use of PMR over sessions resulted in increased
physical awareness and calmness, particularly during anxious moments.
 Deep Breathing Exercises: The client was instructed to practice controlled breathing,
where inhalation occurred through the nose over a slow count of three, followed by a
gentle exhalation through the mouth. These sessions were short, repeatable, and easy to
use outside therapy. The client was encouraged to use this technique whenever he felt
overwhelmed, particularly during cravings or emotional agitation. He later reported using
deep breathing before sleep and during moments of isolation, which he found grounding.
 Sleep Hygiene Training: Given the client’s disrupted sleep patterns—a common
consequence of drug withdrawal—education on sleep hygiene was essential. Strategies
included keeping a consistent sleep-wake schedule, minimizing caffeine intake in the
evening, avoiding use of electronic screens before bedtime, and reserving the bed for
sleep-related activities only. The client responded positively and began reporting gradual
improvements in sleep quality, including fewer awakenings at night and an increase in
total sleep time.
These coping and relaxation strategies were not only beneficial in managing withdrawal
symptoms but also played a role in reducing emotional reactivity and enhancing self-control,
making them essential components of the overall counselling process.
Cognitive Restructuring and Behavioral Tools
Multiple cognitive and behavioral techniques were incorporated to support the client in
identifying distorted thinking patterns, increasing self-awareness, and adopting healthier
behaviors. These tools were introduced gradually, depending on the client’s readiness and
engagement during therapy. The goal was to provide him with practical strategies to cope with
cravings, manage emotional triggers, and prevent relapse.
 42

 Cost-Benefit Analysis
The client was introduced to a structured cost-benefit analysis to evaluate his substance use more
objectively. This involved listing both the perceived advantages (e.g., temporary relief, peer
bonding, escape from stress) and disadvantages (e.g., family conflict, job loss, physical
deterioration, guilt) of drug use. Initially, the client emphasized short-term benefits, indicating
limited insight into the long-term harm caused by heroin. However, through therapist-guided
reflection, he began to recognize the severity of consequences associated with continued use.
This exercise enabled him to develop a more accurate and realistic understanding of how
addiction had negatively shaped his life. The resulting shift in perspective increased his
motivation for change, as he began to view recovery as a pathway to reclaim control over his life
and relationships.
 Daily Thought Records
To help the client gain insight into his automatic thoughts and emotional reactions, daily thought
records were introduced. He was encouraged to document stressful or triggering situations, the
thoughts that emerged in response, and the resulting emotional and behavioral reactions.
Through this technique, the client learned to differentiate between intrusive negative thoughts
and realistic interpretations. For example, in moments of withdrawal, he often recorded thoughts
like “I’ll never be able to quit,” which were linked with hopelessness and craving. With therapist
support, these thoughts were challenged and reframed using cognitive restructuring methods.
Over time, he began replacing irrational beliefs with more balanced alternatives such as
“Recovery is hard, but I’ve already taken the first step.” This practice enhanced his emotional
regulation, reduced impulsive reactions, and promoted more constructive coping responses.
 Functional Analysis (Five W’s)
Functional analysis was used to explore the client’s behavioral patterns and triggers by breaking
down specific drug-use episodes using the five key questions: What happened? Where did it
occur? With whom? Why did it happen? And what was the outcome? Initially, the client
was hesitant and claimed he was “not educated enough” to understand the exercise. However,
through rapport and simplified explanation, he became comfortable participating. He began
identifying clear patterns, such as using drugs when alone at home after arguments or when
visiting certain friends. Recognizing these links helped the client understand how his
environment, emotions, and decisions were contributing to relapse. This awareness enabled more
 43

targeted interventions, such as avoiding specific social settings and building healthier
alternatives.
 High-Risk/Low-Risk Situations
The concept of high-risk and low-risk situations was introduced to help the client differentiate
between environments or contexts that may threaten his recovery versus those that support it.
Through the use of structured worksheets, the client was asked to identify settings, people, or
emotional states that typically preceded drug use (e.g., being alone, feeling ashamed, visiting old
friends who use substances). These were labeled as high-risk situations. In contrast, low-risk
situations—such as attending therapy, spending time with supportive family members, or
engaging in meaningful activities—were highlighted as protective. By recognizing these
differences, the client developed strategies to reduce his exposure to high-risk scenarios and
increase participation in low-risk, recovery-supportive routines. This helped strengthen his
relapse prevention plan and empowered him to take proactive control over his environment and
choices.
Prognosis and Future Recommendations
The prognosis for the client appears hopeful, given his current engagement in treatment,
awareness of the consequences of his substance use, and motivation to rebuild his life. Despite
the severity of his addiction history, the client has demonstrated insight into his behavioral
patterns and emotional struggles. His willingness to participate in psychological treatment,
combined with strong family support and a clear desire for change, suggests a promising
recovery trajectory with appropriate follow-up and sustained effort.
Looking ahead, it is recommended that the client continue his therapeutic journey by actively
practicing the coping skills and emotional regulation techniques introduced during counseling.
Maintaining structure in his daily routine, avoiding high-risk environments, and engaging in
meaningful activities will be essential for relapse prevention. Continued use of relaxation
strategies such as progressive muscle relaxation (PMR) and deep breathing can help manage
residual withdrawal symptoms and emotional triggers.
Participation in peer-led recovery groups or follow-up sessions at the rehabilitation center may
offer additional emotional support and accountability. While intensive therapy may not be
required indefinitely, periodic psychological check-ins are encouraged to monitor emotional
well-being and reinforce progress. Emphasis should be placed on strengthening self-discipline,
 44

maintaining open communication with loved ones, and nurturing the motivation that has led the
client into the recovery phase.

References
 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Washington, DC: Author.
 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(6), 893–897.
 Boardman, A. E., Greenberg, D. H., Vining, A. R., & Weimer, D. L. (2006). Cost-Benefit
Analysis: Concepts and Practice (3rd ed.). Prentice Hall.
 Freeman, C., & Power, M. (2007). Cognitive Behaviour Therapy: A Therapist’s Guide to
the Cognitive Behavioural Approach. Routledge.
 Miltenberger, R. G. (2012). Behavior Modification: Principles and Procedures (5th ed.).
Cengage Learning.
 Mohr, D. C., Goodkin, D. E., Likosky, W., Gatto, N., Baumann, K. A., & Rudick, R. A.
(2003). Treatment of depression is associated with suppression of non-specific and virus-
specific immunity in multiple sclerosis. Archives of Neurology, 60(5), 651–656.
 Rotter, J. B., Lah, M. I., & Rafferty, J. E. (1992). Rotter Incomplete Sentences Blank
Manual. New York: The Psychological Corporation.
 Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7(4), 363–
371.