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BIO DATA
Name: A.S
Age: 23
Sex: Male
Education: Metric
Occupation: Jobless
No. of Siblings: 2, (1 brother)
Birth order: 2nd
Religion: Islam
Informant: Uncle
REASON FOR REFFERAL
The client was taken from the Addiction Ward of Punjab Institute of Mental Health and
was referred for the purpose of psychological assessment and management.
PRESENTING COMPLAINTS
According to the clients:
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According to the Informant:
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HISTROY OF PRESENT ILLNESS:
Mr. A.S is 21 years old, unmarried male. The client has been suffering from the problems
of increased intake of tobacco cigarette, and alcohol, insomnia, loss of appetite, weight
loss, aggression, restlessness, agitation, low mood, easily fatigued, muscles aches/cramps,
headaches, weakness, guilt/regret feelings. Due to excessive use of alcohol the client’s
functioning decline and he was unable to do work. His health has declined alarmingly.
The history of present illness started in 2008 when the client was 18 years old; he
developed friendship with drug users and started to indulge in bad activities. The client
was in metric class when he started to smoke cigrates along his friends and gradually
become dependent of smoking. The client belonged to a family of high socioeconomic
status and has excess of money. The clients friends also belonged upper class.
The clients reported that his father had died when he was one year old child. After the
death of his father, the clients mother was shifted to her brother home. The clients alone
brother had went to the England for horse riding. These events made client freer. He had
complete freedom to move with friends and spent his time with them. Nobody, at home,
had ever asked him about his routine of life. The client completely had lack of parents
monitoring.
The clients reported that he used to move with his friends all the day and at night. They
all mutually arranged parties in which they drink together. The client told that in these
parties they invited their girlfriends and they enjoyed these parties. The clients friends
had great fun at these parties. These parties attract the more and motivate him to drink
more and more. The client and his friends had a great interest in the girls. They often go
on dates with the girls.
The client reported that he also engaged in these activities and get enjoyed. The client
was happy overall at this sort of routine of life. But the clients problems started when he
started to take heavy dosages of the alcohol. The clients reported that he was taking a
normal dosage of alcohol but when he fall in love with his neighborhood girl; he started
to take excessive alcohol. The client was in a mature age when started to love that girl.
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He was made in his love. He often brought precious gifts, jewelry and cloths. They often
go at dates and enjoyed the company of each other. During the interview the client had
disclosed that he also had sex with her. On the other side, the girl showed that he was also
in love with him but in fact she was betraying him. Soon, the client realized the feelings
of his beloved. It was unbearable for the client and he became depressed. He started to
take heavy dosages of alcohol. But the client was still serious about her and wants to
marry with her. He told his beloved that he wants to marry with her and she also accepted
his proposal. She asked him that she was ready to marry with him but his mother should
come at her home with his proposal. The client agreed and promised the girl.
When client told about his love story to his mother and asked her to go his beloved home
with his proposal. The clients mother annoyed at his desire and refuse to go his beloved
home. The clients mother told to client that they never marry in a low socioeconomic
family and it is wise to him to forget her. This entire situation made the client depressed
and distressful. He stopped to go outside the home and started heavy drinking. The clients
mother became anxious at overall situation. The clients refused to take his meals and
started to spent sleepless nights. He wanders whole the night along his friends and takes
heavy dosages of drinks. The client reported that due the habit of wondering and alcohol
usage he was arrested many times. But due to his strong and well to do family status he
was resealed soon.
The clients mother was too upset at the clients condition. She understands the client many
times to avoid his friends company but he always ignored her advices. The circumstances
were gone badly to clients mother and she did not like such attitude of his son. She
decided to cure the clients drinking habit and she took him at the Punjab Institute Mental
Health (PIMH) for proper cure of his alcohol addiction. Here the client was admitted
after some assessment and now client was at the Drug Addiction ward of the PIMH.
FAIMLY HISTROY:
The client belonged to a well to-do family and had an upper socioeconomic status. They
had all luxuries of the life. They were spending happy life with excess of wealth. They
never bother for their expenses. They live in a nuclear family system.
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The client reported that his father died in 1987 due to heart attack. At the death of his
father he was one year old child. His father education was graduation. He had his own
business. According to the client his father had a strong personality. He was the
hardworking person. He loved his both children too much. His father was found of horse
riding. He often had been gone to race course club for races. According to the client his
father was the member of race course club. There he used to like drink with his friends.
In the death of the clients father drinking was main contributing factor. His father’s
relationships with this wife were congenial and satisfactory. He had good mutual
understanding with her wife and cared for her a lot.
The client’s mother was alive. Her age was 30 year and she was a house wife. Her
education was graduation. She had been living in his brother’s house after the death of his
husband. She had a kind and loving nature personality. She always takes care of his
children. She had no conflict with his husband. But she had a conflict with the client on
the issue of his marriage. The clients likes a girl and want to marry with her but his
mother was not agreed. Overall she had a soft, loving and caring personality. Her
physical and psychological health was quite good.
The client had 2 siblings; 1 brother. The first born was his elder brother. He was 26 old
male. He was unmarried. His education was graduation. He was a good horse rider.
During his studies he had taken the horse riding training. After fully trained in horse
riding he went to England. There, he joined the horse riding club and started to take part
in the races. He was a professional horse rider and it was also his source of income. He
was happy and living a good life. He was the sole earner of his family. He earned 1,
20,000 monthly which is enough for him and his family needs. According to the client his
brother loved him too much. He always sends him his pocket money separately. He had a
friendly and satisfactory relationship with client. He had a good physical and
psychological health.
The second borne was the client himself.
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PEERSONAL HISTROY
Birth and Early Childhood:
According to the clients mother his birth was normal. The health of client’s mother was
good at the time of his birth. She had no prenatal and postnatal problems. The client’s
birth was normal at home. Her birth weight was average and the mother didn’t suffer
from any illness during pregnancy. He achieved all the milestones at the appropriate age.
The client started talking at the age of 9 month and same like client started sitting,
crawling, standing, walking and using toilet at appropriate age. According to the clients
mother he was very sensitive and aggressive child. He became easily angry at little
things.
Educational History:
The client got admission at the age of 5 years in school. He was happy at that time
period. The client reported that he was a bright student and always got positions.
According to the client he had been participating in extracurricular activities. His teachers
admired him and like him. He had good relationships with his teachers. According to the
client he had friendly relations with all his class fellows and used to play with them. He
also used to help them in their homework and in the preparations of the exams.
Social History:
The client had strong social ties. He used to spend most of his time with his friends
outside the home. The client reported that his social relations spoiled his life. He had
many friends in his life. All of them belong to upper class. The client reported that he
likes the company of his friends. He spends much time with them. He used to do
wandering all the night with them. They mutually go to clubs. All of his friends were
drinker and they drink regularly. The client also drinks with them. They were happy with
their habit of drinking. They mostly drink in a company. They all fond of late night
parties and attend them regularly. The clients had happy and satisfactory relationships
with his friends. They often arrested due to their habit of drinking. But they released soon
due to their status influence.
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Sexual History:
The client reported that he reached puberty at age of 16 years. He was exited at the
developmental changes and not confused on these changes in body. He got information
related to sexual information from his friends. He was found of reading romantic novels
and watching romantic movies. He had great interest in opposite sex. The client reported
that he often flirt the girls along with his friends. They had sexual relationships with
many girls. The client also took part in these activities. The client reported that he got his
first sexual experience with a girl who lived in his neighborhood. According to the client
she was a beautiful girl and he was in love with her. He often used to gift her expensive
articles. The client also reported that he also used to give her money. The girl belonged to
a low socioeconomic status. But the clients feelings and affections with her was true. On
the other side the client a source of money to her. She always demands gifts, money and
cloth. The client had become blind in his love want to marry with her. The client
discussed all the matter with his mother and asks her, he wanted to marry with her. But
the clients mother did not accepted the proposal. She was not even refused but also
warned him to remain away from her. On the other side that girl also betraying him. He
was so upset at overall situation. He used to drink in heavy dosages. He still loves that
girl but his mother was not agreeing to accept his proposal.
Occupational History:
The client reported that he was unemployed. After his matriculation, he started to take
training of horse riding like his brother. But he could not keep himself to carry on it. He
left the training after 3 months due to his drinking habit. He felt that he was unable to get
this training. He felt uneasy at the training. His brother wants to see him as horse rider.
But the excess of wealth and his bad company made it difficult for him. Overall, he had
no interest in work.
PREMORBID PERSONALITY
The client reported that his life before starting drinking was quite normal and happy. He
was living a joyful life and spends most of his time with his friends. According to the
client he uses to go outside on his motor bike with friends. His mother is happy with him
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because he is an obedient son. His uncle was also happy with him. The client reported
that he often remembers his father. His father’s memory makes him sad. The clients
reported that he is fond of horse riding and wants to become a horse rider like his brother.
The clients mother reported that his son is a good child but the bad company makes him
sick. She also reported that the client is a good student in his studies and also offer his
prayers five times in a day.
ASSESSMENT
Informal Psychological Assessment
Clinical Interview
Behavioral Rating of Client Symptoms
Mental Status Examination
Baseline Chart
Formal Psychological Assessment
Intellectual Assessment (Standard Progressive Matrices Test)
Personality Assessment (Rotter Incomplete Sentence Blank )
Diagnostic Assessment (Minnesota Multiphasic Personality Assessment)
INFORMAL PSYCHOLOGICAL ASSESSMENT
Clinical Interview
Informal psychological assessment was carried out in the form of interview of the patient.
In different sessions the client was examined. His nature and severity of the illness was
been explored.
Mental status examination:
The client was a weak boy of 21 years. He was not sitting in relax posture. He reported
that he was feeling pain in his body and there were crams as well. He was in uneasy
posture. His face was showing fatigue and tiredness. The color of the hair of client was
black and texture was not good. He was wearing shalwar kameez. His height was normal
but body weight was low. The client was maintaining good eye contact. He was
cooperative and was not looking here and there. His facial expressions were sad. He was
depressed. The client was friendly. He was looking older than his apparent age. The
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motor movement of the client was good. The client showed no psychomotor agitation.
Due to absence of drugs his motor movements were slow as he was feeling pain and
crams in the body. The rate of his speech was fast. The client was interested to indulge in
conversation at a very good pace but his condition was not allowing him. The volume of
the client’s speech was good. He was speaking in high tone. No stammering or stuttering
was observed. The client rated his mood at 5 and he was looking quite upset. Stream of
thought was good the thought content was his girl friend and substance he abused. No
hallucinations or delusions were observed. The client clearly lacked in abstract thinking.
He was not been able to tell the meaning of proverbs. The client had good attention and
concentration as well. The client’s orientation about time, place and person was intact
and he answered correctly all the questions. The client’s memory was also intact and he
was able to tell about recent, recent past and remote memory. His judgment was also
good
Rating of the symptoms of the Client
Table: Client’s, and his Mother’s (0-10) Rating of the symptoms of the Client
S. No. Symptoms Client’s Rating Informant’s rating Mean score
1 Insomnia 7 8 7.5
2 Loss of apatite 6 7 6.5
3 Aggression 8 9 8.5
4 Wight loss 6 7 6.5
5 Easily fatigued 7 8 7.5
6 Work desire 5 6 5.5
7 Headache 7 8 7.5
8 Muscle crams 8 9 8.5
9 Restlessness 8 8 8
10 Low mood 9 8 8.5
Base Line Charts:
A baselines chart consists of repeated measurement of the natural occurrence of a target
behavior prior to the introduction of the treatment (Splegler and Guevermont, 1998). For
the client base line charts were designed measuring anger and headache. According to the
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base line chart the client had lost pleasure in daily activities, is experiencing headache.
The charts were made and rated for a week to observe and note down the client’s acts as a
result of headache and aggression his average intensity of the thought was 10 in the
whole weak.
FORMAL PSYCHOLOGICAL ASSESSMENT
INTELLECTUAL ASSESSMENT
Standard Progressive Matrices
Test administration:
The test was administered on April 13, 2011, in ventilated room. The client was sitting on
a chair and the instructions were given according to the manual. He took 30 minutes to
complete the test.
Behavioral observation:
A.S was a 23 years old male. He was an averaged looking young adult of normal
heighted and medium physique. He entered the room, walk fastly. He was dressed up in
Shalwar Kameez and was unshaved. He took his seat and passed a smile. He was
cooperative and answered all the questions and was following the instructions that were
given to him. He completed the test in 13 minutes.
Quantities Analysis:
Administration of the SPM
Showing the Subject’s Score Analysis
Raw Scores Percentile Grade discrepancies Time
Taken
31 25th IV 0,1,-2,-1,1 30 minutes
Qualitative Analysis:
The subject total row score of 31 which corresponded to 25 th percentile rank. The
percentile rank shows the position in contrast with high and low achievers. The 25 th
percentile shows that the performance of the client is intellectually below average in the
test. This means that he has surpassed 24 % of his age group and has below average
intellectual capacity, comprehension and reasoning ability. And 75 % people of his age
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are above him. It reflects that his capacity meaningless figures by seeing relationship
between the working at adequate level. According to his percentile and row score he
receives an “IV Grade”. It indicates that the client is definitely average in intellectual
capacity.
The distribution of score on five sets shows that there are some discrepancies. The
difference between the obtained and expected scores on set A, B, C, D, & E is 0, 1, -2, -1,
1.These discrepancies show that client test performance is consistent and his intellectual
capacity as indicated by test is valid.
The client result is reliable and indicates that the client is definitely below in average in
intellectual capacity and can be correlated well with his background information. The
client performance on Standard Progressive Matrices relate to his educational background
and social status.
PERSONALITY ASSESSMENT
Rotter Incomplete Sentence Blank
Behavioral Observation
Mr. S.A was 23 years old young man. He was bored to hear about the test. After the some
motivation given to him he was agreed to complete the test. He was anxious about test
why it was so lengthy. He answered every question calmly. He made a good cooperation
in spite of his boredom. The client was given instructions according to the manual. The
time taken by the client was considerably more than the normal subjects. He was
thoughtful and suspicious by his gestures. He took 1hours and 30 minutes to complete the
test. He was curious to know the reason of the test.
Test Administration
The RISB was administered on April 13, 2011 in a well-lit ventilated room in PIMH. The
client was sitting on a chair and instructions were given according to manual. The room
was free of distractions.
Results
Quantitative Analysis
Positive responses Conflict responses Neutral responses
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P1 1 C1 6 N 6
P2 8 C2 6
P3 5 C3 7
Total 14 Total 19 Total 6
%age 35% %age 50% %age 15%
Raw Score Cut off Score Remarks
126 135 Normal
Qualitative Analysis
Familial Attitude
There are some items like 2 and 30 showed the conflict related to the familial attitude.
These items showed the conflict related to his family and his habit of drug addiction.
Item no 2 showed his conflict that due to his problem of drug addiction, he had to face
the persuasion hate of family members.
Item no 30 showed conflicts related to his related habit of drug addiction. He was really
upset at his problems.
Social and Sexual Attitude
The items showed by items 14 and 19 the conflict related to the social conflicts.
Item 14 showed the social attitude with his past school life as it was good that showed
that the client was happy in the past but now a days he lose his mental health.
Item 19 showed conflicts related to the people as they scourge and hat him as he was
addicted.
General Attitude
Some items showed the conflict related to his general attitude. For example items showed
general attitude are 5 and 9.
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Item no 5 showed his conflict that due to his problem of drug addiction, he had to face
the persuasion hate of family members.
Item no 9 showed conflicts related to his habit of drug addiction. He was really upset at
his problems and felt regrets over his attitude.
Character Traits
Some items showed his character traits for example items 1, 18 and 32.
Item 1 showed his characteristic related to his extrovert traits of personality as he likes to
meet people and have their company.
Item 18 showed his character trait related to his nerves as they were weak.
Item 32 showed his character trait related to his worries.
Summary
The client score indicated that he is normal as his score as 126 below from cutoff score of
135. However, he showed some conflicts related to his familial attitude as conflicts
related to his family’s persuasion over his drug addicted behavior He also showed
conflict related to social and sexual attitude as people showed hate to him. General traits
showed by him as he, had worries and his nerves were weak and he was may be target to
stress and anxiety.
DIAGNOSTIC ASSESSMENT
Minnesota Multiphase Personality Inventory (MMPI)
Behavioral Observation
Mr. S.A was 23 years old young man. He was bored to hear about the test. After the some
motivation given to him he was agreed to complete the test. He was anxious about test
why it was so lengthy. He answered every question calmly. He made a good cooperation
in spite of his boredom. The client was given instructions according to the manual. The
time taken by the client was considerably more than the normal subjects. He was
thoughtful and suspicious by his gestures. He took 1hours and 30 minutes to complete the
test. He was curious to know the reason of the test.
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Test Administration
The MMPI was administered on April 13, 2011 in a well-lit ventilated room in PIMH.
The client was sitting on a chair and instructions were given according to manual. The
room was free of distractions.
Quantitative Analysis
Scales Raw Scores T-Score
? 22 22
L 4 43
F 16 64
K 09 40
1-Hs 20 60
2-D 33 71*
3-Hy 24 59
4-Pd 39 88*
5-Mf 19 33
6-Pa 24 76*
7-Pt 33 72*
8-Sc 26 51
9-Ma 30 72*
0-Si 30 48
Validity Scales
L Scale
The L scale encompasses 15 items and detects a deliberate and rather unsophisticated
attempt on the part of the individual to present him in a favorable light. It suggests
whether or not an individual is presenting, either consciously or unconsciously, entirely
perfectionist view of himself. The client raw score is 4 and T score is 43 on this scale
which is low score. Low score is also seemed in unconventional normal people. The
score is also associated with the self confidence and willingness to admit minor faults and
shortcomings.
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F Scale
The F scale comprises of 64 items and identifies deviant or a typical ways of responding
to the test items. The client obtained a raw score of 16 and T score of 64. High score in
this range is indicative of individuals who may be malingering, exaggerating symptoms
as a plea for help, may be quite resistant to testing procedure or may be clearly psychotic
by the usual criteria.
K Scale
The client scored a raw score of 9 and T score of 40. Low K scores may be allied with
faking bad profile, exaggerating problems as a plea for help, critical towards self and
others, self dissatisfaction, ineffectiveness in dealing with problems of daily life, showing
little insight into own motives, and behaviors and suspicious about motivation of other
people.
? Scale
The question score is a validity covering of the total number of items put in the “Cannot
Say” category. The client did make use of cannot scale and it indicates that he has
responded to all except 22.
(F-K)
Gough (1950) suggested a method of invalidity by taking disparity of raw F and K scores
and his difference could serve as a useful index for detecting fake bad profile. It indicated
that if the score is greater than +9 or less than -9 than the individual was either faking bad
or faking good. Carson (1969) suggested that a cut off score of +11 yields a more
accurate identification of fake bad profile rather than 9. The differences of raw F and raw
K scores of the client are +7. Positive may point out that the client may be psychotic or
severely disturbed. This can be supported by his case history that he is having symptoms
of auditory hallucinations.
Clinical Scales
Depression (D-2)
The 60 items in scale cover a wide array of behaviors and deals with psychotic
symptoms. The client scored raw score of 33 and a T score of 71 which indicates
depressed and blue. The symptoms showed physical complaints weakness, fatigue and
loss of energy. High scores described as introverted, shy, timed and secretive. A life style
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characterized by withdrawal and lack of intimate involvement with other people is
common.
Psychotic Deviate (Pd-4)
The prominent elevations of the scores appear on Scale-Pd where in the client has
received the raw scores of 39 with corresponding T-score of 74. It is termed as high
elevation, showing that he has cold relationship with family and society. He is indecisive,
angry, rebellious, and impulsive, alienated and has strong disliking for rules and
regulations. In Freudian terms, these are individuals with little or no effective super ego
they have been unable to incorporate the standards of society into their own consciences.
People with high Pd score, are unable to form close relationships, have difficulties in
marriage and work, show poor judgment, act impulsively and demonstrate egocentric
tendencies.
Paranoia (Pa-6)
This scale consists of 60 items and deals with paranoid symptoms. The client scored a
raw score of 24 and T-score of 76. High score on scale 6 (Pa) suggests suspiciousness
and over sensitivity and may indicate paranoid delusions, as well as depressive feelings,
but without the feelings of responsibility that are typically projected onto others. People
may have delusions of reference, grandeur or persecution. Such patients are often angry
or fearful and may plot revenge on others. They may be dangerous to others or even to
themselves as a result.
Other Scales
The client’s score on scales 3, 5, 6, 9 and 0 is 59, 33, 59, and 48 respectively which falls
in the moderate range. The client has masculine preferences in work, hobbies, and other
activities. The client may be tough, aggressive and vigorous. The client may have a
narrow range of interest and has limited intellectual ability. The client may not interact
well socially. The client may be immature and unrealistic. The client may report chronic
fatigue and physical exhaustion. The client may be moderately depressed, anxious and
tense. The client may lack of self confidence. He may be reserved and timid. The client
may be sensitive to what others think about him.
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Two Point Codes
46/64
Patients with this 46/64 code are hostile, immature and emotionally distant, and have
severe problems with adjustment. Their behavior can be irritable and unpredictable, and
they may act out in distrustful ways. Such acts, however are generally poor planned and
impulsive, and be vicious. These individuals can be insecure, socially withdrawn, and
socially isolated. The world is seen as rejecting place. They accept the little
responsibilities for their own behavior and they rationalize excessively blaming their
difficulties on other people.
NEUROPSYCHOLOGICAL ASSESSMENT
Benton Visual Retention Test
Behavioral Observation
Mr. S.A was 23 years old young man. He was bored to hear about the test. After the some
motivation given to him he was agreed to complete the test. He was anxious about test
why it was so lengthy. He answered every question calmly. He made a good cooperation
in spite of his boredom. The client was given instructions according to the manual. The
time taken by the client was considerably more than the normal subjects. He was
thoughtful and suspicious by his gestures. He took 1hours and 30 minutes to complete the
test. He was curious to know the reason of the test.
Test Administration
The BGT was administered on April 13, 2011 in a well-lit ventilated room in PIMH. The
client was sitting on a chair and instructions were given according to manual. The room
was free of distractions.
BVRT Scores on assessment
Showing the expected Correct Scores, according to age range of 15-49 years, estimate IQ,
obtained Correct Score and difference between the expected correct scores and obtained
correct scores according to the pre-calculated norms of administration “A” and remarks.
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Age Expected
IQ
No of expected
correct score
No of obtained
correct score
Differen
ce
category Remark
s
21 95-109 9 8 1 Average As
Expected
BVRT Scores on assessment
Showing the expected error Scores, according to age range of 15-49 years, estimate IQ,
obtained error Score and difference between the expected error scores and obtained error
scores according to the pre-calculated norms of administration “A” and remarks.
Age Expected
IQ
No of expected
error score
No of obtained
error score
Differen
ce
categor
y
Remarks
21 95 -104 5 2 3 High
Average
As
Expected
Qualitative Analysis:
The qualitative analysis showed that the subject obtained correct score was 8 which was
dissimilar to the expected correct score with an Average IQ. The subject’s score on
BVRT indicated that he falls in Average category that suggests satisfactory visual
retention. An analysis of the subject quantitative results further indicates that his number
of obtained error score was 2 and the expected error score was 2. Thus the differences
between errors score 0, which indicate that the subject has no problem in visual retention.
It also provides an estimation of her IQ which is within the range of 95 - 105 categorized
him as mentally High Average.
0Table 5: BVRT Scores on assessment
Table 5 is showing the number of error according to the error category.
Error Left Right Total
Omission 2 1 3
Distortions 1 -- 1
Perseveration -- -- --
Rotations -- -- --
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Misplacement -- -- --
Size error -- -- --
Total -- -- --
Summary:
The Benton visual retention test was used to assess the neurological functions of the
client. The test assessed visual construction skills, visual memory, and visual perception.
The qualitative analysis showed that the client did not show any kind of error and fall in
the category of none defective. Due to his therapy and medication, there was a change in
his condition so it also showed by the scores that he did not show any kind of error. His
visual construction skills, visual memory, and visual perception skills were normal.
TENTATIVE DIAGNOSIS USING DSM-IV-TR
Axis I 303.90 Alcoholic Dependence
Axis II V 71.09 No diagnosis
Axis III None
Axis IV problems related to the social environment (influence of
friends)
Axis V GAF= 31-40 (current)
DIFERENTIAL DIAGNOSIS
Substance disorder is distinguished from non nonpathalogical substance use (e.g “social”
drinking) and from the use of medications for appropriate medical purposes. Repeated
episodes of Substance Intoxication are almost invariably prominent features of Substance
Abuse or Dependence. However, one or more episodes of Intoxication are not sufficient
for a diagnosis of either Substance Dependence or Abuse. If the symptoms are judged to
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be a direct physiological consequence of a general medical , the appropriate Mental
Disorder Due to a General Medical Condition should be diagnosed.
PROGNOSIS
The client’s prognosis was promising and good because he appeared to be very motivated
and showed full co-operation. He wanted to get relief as soon as possible and wanted to
start a new life and has plan to get further education and then getting married, so it seems
to be have good insight to some extent.
CASE FORMULATION:
The client was 21 years old single male with the education up to metic with the
complaints of alcoholic dependency. The client was well dressed, neat and clean. He
showed full co-operation in first meeting. He appeared to be friendly and cooperative. He
maintained proper eye contact and appropriate posture in all sessions. His speech and
communication was appropriate though at some points he showed some pauses. His
speech was clear, fluent and coherent. He explained his problems and history in detail
and emphasized a lot on his friend’s role in his that current condition. He also reported
loss of energy, fatigue and stiffness of body and neck repeatedly. But he wanted to get rid
off from this situation as soon as possible. He was overall well aware and well oriented
with time, person and place. He did not report any memory problem but reported lack of
concentration in his school time and during job. He was well aware that he has some
problem and was ill and here to seek for psychological help and treatment so he co-
operates in all things.
MSE, case history interview, MMPI was used to assess diagnostic/screening criteria for
assessment and for intellectual functioning SPM was used, and to evaluate the personality
of the client, the RISB was administered on the client to assess his personality, BVRT
used to assess the client’s neuropsychological functioning.
The clients history suggested that the leading predisposing factors of his alcohol-
addiction was his age, gender, and parental drug abuse history. Many researches indicate
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that the age is a common factor of drug abuse. As the child reaches in the adolescence he
involved in such drug abusing behavior starting from smoking and taking beverages. For
this kind of behavior society and peers group have strong impact. As the case, with client
he belonged to an upper class family and had peer relationships with such guys whom are
also belonged to upper class family and in the habit of drug abuse. Thirteen- to fifteen-
year-olds are at high risk to begin drinking. According to Johnston, (1995) results of an
annual survey of students in 8th, 10th, and 12th grades, 26 percent of 8th graders, 40
percent of 10th graders, and 51 percent of 12th graders reported drinking alcohol within
the past month . Binge drinking at least once during the 2 weeks before the survey was
reported by 16 percent of 8th graders, 25 percent of 10th graders, and 30 percent of 12th
graders. Young people at highest risk for early drinking are those with a history of abuse,
family violence, depression, and stressful life events. People with a family history of
alcoholism are also more likely to begin drinking before the age of 20 and to become
alcoholic. Such adolescent drinkers are also more apt to underestimate the effects of
drinking and to make judgment errors, such as going on binges or driving after drinking,
than young drinkers without a family history of alcoholism. (Hingson & Heeren 2006). ).
A potentially powerful predictor of progression to alcohol-related harm is age at first use.
Evidence suggests that the earlier the age at which young people take their first drink of
alcohol, the greater the risk of abusive consumption and the development of serious
problems, including alcohol disorders (Chou & Pickering, 1992).
As the age was concerned with onset of the clients alcohol abuse, clients gender is also a
contributing factor of his problem. Many researches indicate that the alcohol abuse is
more common in males as compared with females. Drinking is associated with displays
of masculinity or male camaraderie, this may encourage male drinkers to deny or
minimize problems resulting from their drinking, or to regard drunken behavior as
normal or permissible (Capraro, 2000; Nayak, 2003; Nghe, Mahalik, & Lowe, 2003),
even when it leads to violence (Graham & Wells, 2003; Hunt & Laidler, 2001; Tomsen,
1997). At the other extreme, surveys in many different populations consistently find that
men are more than twice as likely as women to report heavy episodic drinking (or "binge"
drinking, of at least 60 grams of ethanol in a day) (e.g., Janghorbani et al., 2003;
Malyutina et al., 2001; Miller et al, 2004; Neumark, Rahav, & Jaffe, 2003; Welte et al.,
21
1995). Recurrent alcohol intoxication is much more prevalent and more frequent among
men than among women (Hao et al., 2004; Makela et al, 2001; Rehm et al., 2001).
Consistent with gender differences in heavy drinking, surveys in many countries find that
men are more than twice as likely as women to have alcohol use disorders. Men are much
more likely than women to report diagnosable alcohol abuse, either currently (e.g., Bijl et
al., 2002; Dawson, Grant, & Stinson, 2004; Hao et al., 2004; Kringlen, Torgersen, &
Cramer, 2001; Yamamoto et al., 1993) or as a lifetime experience (Kawakami et al.,
2004; Meyer et al., 2000). Men are also much more likely than women to report
diagnosable alcohol dependence, currently (e.g., Bijl et al., 2002; Hao et al., 2004; Hasin
& Grant, 2004; Kawakami et al, 2004; Spicer et al., 2003) or as a lifetime experience
(Dawson & Grant, 1998; Heath et al., 1997; Kawakami et al. 2004; Meyer et al, 2000).
The most common hypotheses to explain why men and women differ in their drinking
behavior argue that alcohol consumption both symbolizes and enhances men's greater
power relative to women (McClelland et al., 1972). Alcohol consumption, particularly in
large quantities, has been an emblem of male superiority, a privilege that men have often
reserved for themselves and denied to women (Martin, 2001; Nicolaides, 1996; Purcell,
1994; Suggs, 1996, 2001; Wang et al., 1992; Willis, 1999). Alcohol consumption in all-
male groups may affirm the privileged status of being a man rather than a woman
(Campbell, 2000).
The third underlining factor of clients alcohol abuse was the genetically related to his
problems. According to the client, his father was also a regular drinker. The clients
reported that his father has many friends at the race course club and he used to take
drinks with them. The genetic factor always played a significant role in developing
psychological problems. Many investigations showed that the genetic predisposition is
related to the developing psychological problems later in the children. The idea that
alcoholism runs in families is an ancient one. In recent decades, science has advanced this
idea from the status of folk-observation to systematic investigation (Roe, 1944 and
Goldman, 1986). In the 1970s, studies documented that alcoholism does run in families
(Goldwin & Cotton, 1979). Researchers investigate possible genetic components of
alcoholism by studying populations and families as well as genetic, biochemical, and
22
neurobehavioral markers and characteristics (Cloninger, 1990 and Mcgue, 1991). Two
major methods of investigating the inheritance of alcoholism are studies of twins and of
adoptees (Pikens & sivkis, 1991). Twin studies compare the incidence of alcoholism in
identical twins with the incidence of alcoholism in fraternal twins (Hrubec, 1981 &
Pikens, 1988). If there is a genetic component in the risk for alcoholism, then identical
twins, who have identical genes, would be expected to exhibit similar histories of
developing alcoholism (or not developing alcoholism). Fraternal twins, who are
genetically different individuals born at the same time, would be more likely to differ in
their tendencies to develop alcoholism. In general, researchers using the twin method
have found these expectations to be true.
The precipitating factors of clients alcohol abuse are his social circle, friends and peer.
The client reported that he has many friends and all of them are alcohol users. The client
also started to take drinks with them. The researches indicate strong association in drug
abuse and social influence. Social factors such as peers, friends and availability of drug
are main contributing factors in adolescence. Alcohol use continues to be an important
public health problem. Recent national survey data indicate that 41% of current 8th
graders, 62% of 10th graders, 73% of 12th graders, and 85% of college students have
used alcohol (Johnston et al., 2007). Even more troubling is that 11% of 8th graders, 22%
of 10th graders, 25% onf12th graders, and 40% of college students reported heavy
episodic drinking. Psychosocial factors play a key role in the onset and developmental
progression of alcohol use. These include social influences from parents and peers,
perceived drinking norms, and positive expectancies.
Moreover, research has shown that social influences to drink outranked cognitive and
behavioral factors in predicting initial involvement with alcohol longitudinally (Ellickson
and Hays, 1991). According to Social learning theory (Bandura, 1977) provides a useful
theoretical framework for understanding the role of social influences, suggesting that
adolescent alcohol use is a learned behavior acquired through a process of observation,
modeling, imitation, and social reinforcement.
Peers and friends also exert a potentially powerful social influence on adolescent drinking
behavior. Adolescent drinking has been associated with alcohol-using peers in
23
predominantly white samples (e.g., Kandel, 1986; Kandel and Andrews, 1987; Sieving et
al., 2000). Research indicates that social influences to drink stem from both the initial
selection of friends (i.e., choosing friends) and the subsequent maintenance of friendships
with positive reinforcement and other rewards (Windle, 1999).
According to the clients the social environment in which is living is highly suggestive of
such behaviors. The social environment selection have great role in developing alcohol
abusive behavior. Although social influences typically have been conceptualized as
directly shaping drinking behaviors in adolescents, it is likely that individuals are not
passive recipients of environmental influences and that the association between
environment and drinking behavior is reciprocal rather than unidirectional; that is,
individuals are affected by social environments, but they also select the environments to
which they are exposed.
Selection of social environments that are conducive to drinking may play an important
role in alcohol use and problems (Britt & Campbell, 1977; Wood, Maddock, Hallak,
Mitchell, & Stevenson, 2000) and may account, in part, for the effects on alcohol use of
certain demographic and personality characteristics that may influence social selection.
Evidence from both the genetic and the social psychological literature suggests that
individuals may present to a social environment with specific (possibly heritable)
individual risk factors, which may interact with the environment to result in increased
alcohol consumption (e.g., Fitzgerald & Zucker, 1995; Legrand, McGue, & Iacono, 1999;
Maisto, Carey, & Bradizza, 1999; Searles, 1988). Within this interactive framework, an
environmental selection perspective suggests that dispositional or static characteristics
may influence behaviors directly and indirectly by affecting the types of environments to
which one “chooses” to be exposed (Robins, Elliott, & Pattison, 2001; Searles, 1988).
Recent work in the area of social network models of behavior points to evidence that
social networks are, in fact, chosen as a result of the particular sociodemographic,
personality, or other types of characteristics of the individual who selects them (Robins et
al., 2001). As a result, these selected environments may support and enhance
predispositions to certain behavioral outcomes.
24
The maintaining factor of clients alcohol abuse is his motivation for drinking. The clients
reported that he had a great desire for taking alcohol. He reported that the he used to
drink to avoid his problems such as to forget his beloved response and his conflict with
his mother. He reported that he was unable to give up the drinking behavior; it is the only
way to cope with his problems. Researches indicate that the individual motivations plays
important role in maintenance of alcohol abusive behavior. A large body of research on
the etiology of adolescence drinking has identified social and psychological correlates of
alcohol use and misuse (e.g., Baer & Carney, 1993; Fromme & Ruela, 1994; Wechsler,
Dowdall, Davenport, & Castillo, 1995). Furthermore, many have stressed the role of
specific motives for drinking in this population (Carey & Correia, 1997; Karwacki &
Bradley, 1996; MacLean & Lecci, 2000; Stewart & Zeitlin, 1995).
According to Motivational models assert that an individual’s reasons for engaging in a
behavior are important in both the initiation and perpetuation of that behavior.
Applications of motivational theory to drinking behavior have consistently supported the
importance of motivational factors in alcohol use across adult (e.g., Abbey, Smith, &
Scott, 1993; Carpenter & Hasin, 1998), adolescent (Bradizza, Reifman, & Barnes, 1999;
Windle, 1996), and college (Carey & Correia, 1997; Kassel, Jackson, & Unrod, 2000;
Ratliff & Burkhart, 1984) populations.
Different types of drinking motives have been delineated. Most commonly, drinking
motives have been categorized according to affective dimensions (e.g., drinking to
enhance or stimulate positive emotion, drinking to cope with negative emotion).
However, motives pertaining to social factors (social reinforcement) also have been
thought to be important in understanding drinking behavior.
In 1988, Cox and Klinger posited a theoretical model of drinking motives that took into
account the interplay between these motives and specific psychosocial antecedents. These
authors hypothesized that factors such as mood and mood-relevant expectancies
contributed to the motivation to drink alcohol, playing a critical role in the determination
of alcohol use.
25
Cooper, Frone, Russell, and Mudar (1995) proposed and tested a motivational model of
drinking that was consistent with Cox and Klinger’s theoretical model. Using structural
equation modeling procedures, they tested whether distinct motives (enhancement and
coping) were associated with alcohol involvement and whether they played a central,
intervening role in the relationship between more distal psychosocial factors, such as
alcohol outcome expectancies (i.e., social enhancement and tension reduction), sensation
seeking, coping style, and negative emotion. Strong empirical support for this model was
demonstrated in cross-sectional samples of both adolescents and adults; enhancement
motives and coping motives were associated with alcohol use, and each was linked to
distinct emotion and expectancy antecedents. Furthermore, enhancement motives
mediated the associations of sensation seeking and enhancement expectancies with
alcohol involvement, and coping motives mediated the associations of negative emotion
and tension reduction expectancies with alcohol involvement.
Coping motives for alcohol consumption are presumed to operate on the principle of
negative reinforcement and involve drinking to ameliorate negative emotions or to make
such emotions more tolerable (Abrams & Niaura, 1987; Cooper, Russell, Skinner, Frone,
& Mudar, 1992; Farber, Khavari, & Douglass, 1980). Several studies of coping motives
and alcohol involvement in college samples have suggested that drinking to cope is a
particular risk factor for alcohol problems (Carey & Correia, 1997; Kassel et al., 2000;
MacLean, Collins, Morsheimer, & Koutsky, 1999).However, some evidence suggests
that coping motives may affect alcohol misuse less strongly in drinkers for whom heavy
alcohol use is more normative (i.e., older adolescents or college students; Bradizza et al.,
1999; Perkins, 1999).
MANAGEMENT PLAN
• Psycho education
• Supportive Therapy
• Behavior Therapy
• Cognitive Therapy
26
• Family Therapy
Short Term Goals
• Supportive work to be done to develop rapport and trust in patient.
• Psycho education to be done to his help the patient to understand the nature
causes of illness, mode of treatment and his cooperative attitude in treatment.
• Relaxation techniques to be taught help him to overcome his angry feelings, calm
down and to respond appropriately to angry feelings when they occur.
• Assertive training to be done to teach him to express his angry feelings in a direct
and non confrontational manner.
• Activity scheduling to be used to provide him structured and organized day by
developing purposeful activities.
• Cost benefits analysis to be used to enhance his awareness about the advantages
and disadvantages of drug use.
• ABC model to be taught to explain the client his way of thinking and its
emotional behavioral consequences.
• Disputing to be used to help him to identify and debate his rigid and inflexible
beliefs regarding drug addiction.
• Rational coping statements and encouraging phrases consistent with social reality
to be used to reinforce the idea for him.
• Self management skills to be taught to enable him to modify his own life in
relation to substance use.
• Mastery pleasure technique to be used to give him a sense of achievement by
scheduling potentially, pleasurable and purposeful activities.
• Problem solving skills to be taught to deal with his problems positively rather
than depending on drugs.
27
• Distraction techniques to be used to reduce craving.
• Assisting the client in restructuring his irrational beliefs by reviewing reality
based evidence and misinterpretation.
Long Term Goals
• Regular follow up sessions.
• To decrease overall intensity and frequency of angry feelings and to increase se
the ability to recognize and appropriately express angry feelings as they occur.
• To come to an awareness and acceptance of angry feeling while developing better
control and more serenity.
• To become capable of handling angry feelings in constructive ways that enhances
daily functioning.
• Establish firm individual self-boundaries and improved self worth.
• Break away permanently from any abusive relationship.
• To decrease the present conflicts parents and siblings while beginning to let go or
resolving past conflicts with them.
• To achieve reasonable level of family connectedness and harmony where numbers
support, help and concerned for each other.
• To accept responsibility for own behavior and keep behavior with in the
acceptable limits of the rules of society.
• To develop and demonstrate a healthy sense of respect for suicidal norms, the
rights for others and need for honesty.
• To improve method of relating to the world especially authority figures, behave
realistic, less defiant and more socially sensitive.
• To maintain consistent employment and demonstrate financial and emotional
responsibility.
28
• To increase goal directed behaviors.
• To focus thoughts on reality.
Therapeutic Techniques to Obtain Short Term Goals
There are following therapies which will help in the treatment of the client
Psychoeducation
Psychoeducation can be beneficial in the treatment of patients who take drugs and
alcohol (Tracey, 2005). Psychoeducation was first developed by Brain E. Tomlinson in
1962. Psychoeducation refers to the education offered to people who live with the
psychological disturbance. It takes place in one-on-one discussion or in groups by any
qualified health educator as well as health professionals. It consists of giving patients and
other relative’s adequate knowledge about disorder and teaching illness self management
skills so that people have a better understanding of their of their illness and its treatment.
There are several steps involved in psychoeducation. It involves first level partial
objectives and second level partial objectives. At first level (elemental mechanisms),
patient and his family is educated and given awareness about disorder, early detections of
warning symptoms and adherence with treatment. At second level (secondary
mechanisms), the patient and family is educated about controlling stress, achieving
regularity in life style and preventing suicidal behavior. At third level, patient and family
is asked to improve social and interpersonal activity between episodes and increasing
well being and improving the quality of life. Psychoeducation will be beneficial for the
client by learning about the symptoms of drug addiction, expected time course, triggers
of symptoms and treatment strategies. It will help him and his family to know about the
causes of the problems solving skills to better assist the client and his family in dealing
with possible manifestations of the illness and thus promote improved outcome.
Supportive Therapy
Supportive psychotherapy is an eclectic approach that integrates psychodynamic and
cognitive-behavioral model and techniques. It is a dyadic treatment characterized by use
of direct measures to ameliorate symptoms and to maintain, restore or improve self
esteem, adaptive skills and psychological functions (Tracey, 2005). It will beneficial for
29
the client by reinforcing the patient’s healthy and adaptive patterns of thought behaviors
in order to reduce the conflicts. It will be beneficial for the client especially in the
interpersonal context.
Behavioral Therapies
Behavioral therapy will be beneficial for the client as it aims to identify and change
aspects of behavior that may be implicated in the cause and maintenance of drug
addiction. It includes aversion therapy, covert sensitization, activity scheduling, pleasure
and mastery technique, assertive training, problem solving skill and reinforcement.
Aversion Therapy
Aversion therapy will be beneficial for the client by repeatedly presenting him with
unpleasant stimuli while performing undesirable behaviors. After repeated pairings, the
client is expected to react negatively to the substance itself and to lose his craving for it.
The client can be shocked or made nauseas while looking and reaching for a drug. The
unpleasant feelings or sensations will become associated with that behavior (Turner,
Calhoun, & Adams, 1987). It will be beneficial; for the client.
Covert Sensitization
Covert sensitization can be used for the client and in this therapy the target behaviors and
aversive stimulus are associated completely in imagination (Turner, Calhoun, & Adams,
1987). It will require the client to imagine extremely upsetting, repulsive and frightening
scenes when he is taking drug.
Contingency Management Therapy
A contingency contract is a written agreement between a client and one or other people
that specifies the relationship between a target behavior and its consequences (Turne,
Calhoun, & Adams, 1987). It will be beneficial for him by encouraging positive behavior
change such as abstinence by providing punitive measures when engaged in undesirable
behavior.
30
Motivational Enhancement Therapy
Motivational Enhancement Therapy s designed to produce rapid, internally motivated
change this treatment strategy does not attempt to guide and train the client step by step
through recovery but instead employs motivational strategies to mobilize client’s own
resources. It will beneficial for the client by enhancing his motivation level to change his
condition.
Twelve Steps Paradigm
There are twelve steps that are developed for addiction. The idea of a twelve steps group
is that each of the member rows to believe and then live through deeds each of the twelve
steps.
We admitted we were powerless over alcohol in that our lives had become
unmanageable.
Came to believe that a power greater than our selves could restore us to sanity.
Made a decision to turn our will and our lives over to the care of God as we
understood him.
Made a searching and fearless moral inventory of ourselves.
Admitted to God, to ourselves and to another human being the exact nature of
our wrongs
Were entirely ready to have God remove all of these defects of character.
Humbly asked him to remove our shortcomings.
Made a list of all persons we had harmed and became willing to make amends to
them all.
Made direct amends to such people wherever possible except when doing so
would injure them or others.
Continued to take moral inventory and when we are wrong promptly admitted it.
Sought through prayer and meditation to improve our conscious contact with God
as we understood Him, praying only for knowledge of His will for us and the
power to carry that out.
31
Having had a spiritual awakening as a result of these steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs (Finley,
2004).
Activity Scheduling
Activity schedule can be used to keep precise and accurate record of the client’s activity
so that frequency of all the behaviors is fare duly recorded. Those behaviors that need
change/ modification can systematically taper off by exchanging them with desirable
ones (Ellis & Dryden, 1997).
Assertive Training
It can be helpful for the client by increasing his ability to communicate effectively with
people and being able to express needs and feelings in a direct and non confrontational
manner. He will gain confidence and will share his feelings with others in order to clarify
them and to gain insight as to causes. It will encourage the client in taking part in social
activities. It will enhance his well being by learning how to meet others, talk to them,
maintain eye contact, give and receive criticism, express feelings and improve his
relationships with other people (Wykes, Tarriier & Lwis, 1998)..
Behavioral Self Control
The client can be taught ways to resist craving in situation where drug is available. In
learning to resist social pressure to take drugs, relaxation training and stress management
training along with bio feedback and a better diet can all help the client.
Problem Solving Skills
Problem solving therapy was originally developed by Zurilla and Goldfried. Problem
solving refers to a systematic process by which a person generates a variety of potentially
effective solutions to a problem, judiciously chooses the best of these solutions and then
implements and evaluates the chosen solution. Problem solving technique serves a dual
32
purpose by treating the immediate problems for which the client seeks treatment and
preparing the client to deal on their own future problems and it teaches problem solving
skills as a general coping strategy for dealing with problems that arise in course of daily
life. The basic stages of problem solving therapy include adopting a problem solving
orientation, defining the problem and setting goals, generating alternative solutions,
deciding on the best solution implementing the solution and evaluating its effect. In early
stages, the therapist may employ cognitive modeling to demonstrate the problem solving
process. During the third stage, the therapist prompts the client is facilitated with
behavior therapy procedures ( Wykes, Tarrier, & Lewis, 1998). It will be beneficial for
the client by teaching him how to deal with problems in life effectively.
Progressive Muscle Relaxation Technique
Progressive muscle relaxation is a technique for reducing anxiety by altering tensing and
relaxing. It will be useful for the client by reducing anxiety by alternately tensing and
relaxing muscles. The client may start by sitting or lying down in a comfortable position.
With the eyes closed, the muscles are tensed (10 seconds) and relaxed (20 seconds)
sequentially through various parts of the body. The whole PMR session takes
approximately 30 minutes ( Wykes, Tarrier, & Lewis, 1998). It will be beneficial for the
client.
Social Skills Training
Social skills training are another technique that has its origin in social learning theory
( Bellack & Muen, 1994). It helps in decreasing symptoms and increases the adjustments.
The problems that can be targeted with this are the interpersonal inappropriate
communication patterns, socially inept behaviors and problems forming close
interpersonal relationships. In social skills training, the client can be taught
conversational skills , gestures, eye contact, balanced voice tone (as the client is a
stammered), and improved in notion. The client lacks this skills to an extent that he has
cold relationship with father and eldest brother. Thus, by means of role-playing and role
33
rehearsal, he can be trained in how to behave effectively in frustrating, distressing and
threatening situations.
Cognitive Therapies
Cognitive therapy will be beneficial for the client by altering maladaptive thought
patterns. It will help him to identify and correct his distorted and negatively biased
thoughts. It will encourage him to reframe the way he thinks about life, to be able to
bounce back from failures more effectively and to recognize and take credit for the good
things in his life. He will think that he has control over what happens to him. It includes
rational emotive behavioral therapy.
Rational Emotive Behavior Therapy
Rational emotive behavior therapy is a comprehensive, philosophically and empirically
developed by Albert Ellis based psychotherapy which focuses on resolving emotional and
behavioral problems and disturbances and enables people to lead happier and more
fulfilling lives. It can be useful for the client by giving him awareness that behaviors and
emotions are the result of what the person thinks about himself. It includes
Disputing
Disputing is an active approach developed by Albert Ellis for helping clients to evaluate
the helpfulness and efficacy of elements of their belief system (Dryden, 2003). It allows
the patients to identify, debate, and ultimately replace their rigid, inflexible beliefs which
are generally getting them into trouble. Disputing can be at four levels including
functional, empirical, logical and philosophical disputing. Functional disputing is used to
question the practical application of the patient’s belief and their accompanying emotions
and behaviors. The therapist systematically shows client how much they potentially have
to gain from working at replacing the irrational beliefs with their more flexible and
realistic rational beliefs. Empirical disputing is used to evaluate the factual components
of the clien t’s beliefs and to test the specific beliefs are consistent with social reality
or not. The task with an empirical dispute is to help the client to understand that he has
34
been holding onto a belief which is insupportable and when questioned does not make
sense, logical disputing is focused on questioning the illogical leap the client is making
from desires or preferences to demands in his irrational thinking. Philosophical disputing
address a life satisfaction issue. It will help the client in evaluating the helpfulness and
efficacy of his belief system and to change his irrational beliefs.
Rational Coping Statements
Rational coping statements are self statements which usually are implemented after
forceful disputing has been accomplished but can also be used while the client is in the
process of exploring his irrational beliefs. These factual, encouraging phrases are
consistent with social reality and clients are encouraged to repeat them consistently to
reinforce idea for them (Dryden, 20033). It can be used for the betterment of the client. It
will help the client to repeat coping statements to reinforce idea for him.
Relapse Prevention
Relapse prevention is a systematic method for teaching recovering patients to recognize
and manage warning signs. It will be beneficial for the client by reviewing potentially
provocative thoughts and experiences which may contribute to relapse impulses, by
brainstorming solutions with the client for problematic situations (Ellis & Dryden, 1997).
Referenting
Refrenting can be executed to get the client rid of the chain smoking (including tobacco
and charas-cannabis). The client can be asked to write down the positives and negatives
or pros and cons of this habit and then choose what should be adopted or not by taking
the decision (By Joseph Danish)
Cognitive Behavioral Therapy
35
CBT was developed by Aaron T Beck and is psychotherapeutic technique that aims to
solve problems regarding dysfunctional emotions, and cognitions through a goal oriented
systematic procedure. It includes
Double Column Technique
Recoding cognitions and responses in parallel columns is a way to begin examining,
evaluating and modifying the cognitions. The patient is instructed to write his cognitions.
The patient is instructed to write his cognitions in one column and then write a reasonable
response to the cognitions in the next column. The written assignment may also include
additional columns for describing the patient’s affect and behavior and the specific
description of the situation or event which preceded the cognition. Thus depending on the
number of columns used the technique may be referred to as the double column, triple
column and even the quadruple column. The rationale for the approach is to teach the
patient more precise discriminations of his emotions and thoughts. The therapist’s major
task is to help the patient think of reasonable response to the negative cognitions. The
therapist’s goal is to increase the patient’s objectively about his cognitions and unpleasant
affect unproductive behavior (Beck, Wright, Newmsn, & Liese, 1993). It will be
beneficial for the client and he will begin examine, evaluate and modify his maladaptive
cognitions.
Downward Arrow Technique
The downward arrow technique is used to identify intermediate beliefs. The therapist
identifies a key automatic thought which he suspects directly stemming from a
dysfunctional belief then he ask the patent meaning of the cognition assuming the
automatic thoughts were true. He continues to do so until he has uncovered one or more
important beliefs. Asking what a thought means to the patient often elicits an
intermediate belief and usually uncovers the core belief (Beck, 1195). It will be beneficial
for the client in order to find out a core belief.
Specific Techniques for Craving
36
There are some techniques used to reduce the aroused cravings and it includes:
Distraction technique
Flashcards
Imagery technique
Rational responding to urge related automatic thoughts
Distraction Technique
The key goal of distraction techniques is to get patients to change their focus of attention
from internal such as automatic thoughts, memories and physical sensation to external.
These techniques are quite simple but they help to diminish cravings. There ere some
steps involved: 1) Instruct patients to concentrate their attention on describe
surroundings. The more they can focus and give details about external events, the more
likely they are to focus less on the internal cravings. 2) Talking can also b used as
distraction and this involves starting a conversation with a friend, relative or to the
therapist. 3) Patients can remove themselves from the cue laden environment. 4) Perform
household chores as a positive distraction. This goal directed activity not only diminish
their cravings but also enhances self esteem. 5) Encourage patient to recite a favorite
poem or prayer (Beck, Wright, Neqwman, & Liese, 1993). It will be beneficial for the
client in reducing his cravings.
Flashcards
When cravings are strong patients seem to lose the ability to reason objectively.
Generating coping statements can be helpful in getting patients through this critical
period. The usefulness of the coping statements can be enhanced by asking patients to
write these statements on flashcards (3*5 index cards). The statements include d are “You
feel more sane you do not use.” “You look good physically, keep it that way”. (Beck,
Wright, Newmwn & Leises, 1993).it will be beneficial for the client.
Imagery Techniques
Imagery techniques can be useful in the reduction of craving and these include image
refocusing, negative image replacement, positive image replacement, image rehearsal and
image mastery. Refocusing is essentially a distraction technique. Patients direct their
37
attention away from internal cravings by imaging external events. Refocusing can begin
first by saying stop. Another imagery technique is negative image replacement. It is
helpful for patients to substitute a negative image regarding the many unfortunate
consequences of taking the drug such as feeling helpless and hopeless. This image will be
strong enough to dissuade them from taking the first drink. Positive image replacement is
a related technique to help cope with cravings and urges the patients imagined themselves
in a positive state such as going back to work and to normal routine. This may diminish
cravings. Imagery rehhearsel should be used when patients are going to be in cue laden
situation (Beck, Wright, Newman, & Lieese, 1993). It will be useful in the reduction of
the craving of the client.
Rational Responding to Urge-Related Automatic Thoughts
Therapists start by training patients to self monitor automatic thoughts when they are
having unpleasant emotions such as anger, anxiety, sadness or boredom. Later the
patients are instructed how to assess their automatic thoughts while experiencing cravings
and urges. It is helpful to have patients carry a therapy notepad and a pen in order to write
down these thoughts. Patients are told that any time they experience strong cravings or
unpleasant emotions they should ask questions to him self. They are instructed to note
any physiological distress and then write down their answers. The daily method is used to
help patients (Beck, Wright, Newman, & Liese, 1993)). It will be beneficial for the client
to diminish his cravings.
Family Therapy
Family therapy usually involves the whole family. The aim is to educate and make them
aware of the state of the client, to clarify any misconception related to the problem and to
guide the whole family in how to resolve the conflicts in healthy way. In the current case,
the client has so many problems regarding the family and home life. His father has a very
complaining attitude towards the client. The client’s parents and siblings can be involved
in the rehabilitation process of the client. They can be educated about the nature of his
problem and how they can build an understanding and warm relationship with him to win
his trust and warmth.
38
SUGGESTIONS AND LIMITATIONS
• There should be an increased number of sessions to get detailed information about
the client.
• Environment should be adequate enough to get full attention of the client.
• The family should be educated to treat him with love and affection.
• Helping him to learn that sharing and feelings and emotions really help him in
alternating memories about stressful life events.
• Family can play an important role in altering the client’s behavior doing things
are in mood consequence with the client.
There were some limitations that were observed
• There was limited number of sessions.
• Environment was not adequate and it was difficult to gain full attention of the
client.
• Client was aggressive and become angry over small things.
• The information was reluctant in giving information about the client.
39
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