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Case Reports of Counseling

Submitted to

Ms. Zaeema Farooq

Submitted by

Naima Mukarram

Msc III (morning)

Roll no # 33

INSTITUTE OF APPLIED PSYCHOLOGY

UNIVERSITY OF THE PUNJAB, LAHORE

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Certificate

It is certified that the candidate, Ms. Naima Mukarram Roll no. 33,Msc III has conducted the

counseling work under the supervision of Ms. Zaeema Farooq and has prepared the counseling

report according to the rules set out for examination by the University of the Punjab, Lahore.

Supervisor

Ms. Zaeema Farooq

(Internal Examiner)

(To be assigned after viva voice examination)

Approved/Rejected/Sought Revision & Re-submission

External Examiner Director

Dated: Dated:
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Acknowledgement

First of all, I would like to thank ‘ALLAH ALMIGHTY’ who has given me the courage and

capability to carry out and complete my report. I would like to thanks the inspiring Course

Instructor Ms. Zaeema Farooq who has given us guideline at every step.

At last, I would like to pay my thanks to the participant of the study who had helped us out and

cooperated in test administration. I am also thankful to the institution of which I have been a

part. Also, I would like to thanks the faculty members, Lab staff and library faculty members

who had helped in completing my report.

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Table of Contents

Topic Page No.

Child Case report 5-25

References 26
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Case report 1

Child Case Report

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1.1 Bio Data of client

Name M.T

Age 14years

Gender Female

Education 8th

No. of Siblings No

Birth Order 1

Religion Islam

Marital Status Unmarried

Father Name M.T

Mother Name N.F

Informant (source) School Principal

1.2 Reason of Referral

The client was taken from Government Girls High School Kasur for psychological assessment

and management with symptoms extreme sadness.

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1.3 Presenting Complaints

The Client presented following complaints that she face in her school and home. She

feels very depressed and even feel headache.

‫میری امی کے انتقال کے بعد میں بہت اداس رہتی ہوں‬

‫جب امی یاد آتی ہیں تو بہت رونا آتا ہے‬

‫میرا پڑھائی میں دل نہیں لگتا‬

‫میرے سر میں اکثر درد رہتا ہے‬

‫مجھے ایسا لگتا ہے کہ میں دنیا میں اکیلی رہ گئی ہوں ۔‬

‫مجھے اپنے ماموں سے بہت ڈر لگتا ہے‬

‫وہ مجھے اور خالہ کو بہت مارتے ہیں‬

1.4 History of Present Illness

The client was taken from government Girls High School Kasur with the symptoms of

extreme sadness. She continued her studies but she her teachers and principal report that the

mood of client is often sad and due to this sadness client face difficulty to pay attention in her

study. The Client is facing this difficulty after the death of her mother. The client problem starts

when she passed her 6thclass. She remember her mother and start weeping. Her mother was only
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one person who understand her. The client was very attached to her mother and share every

problem with her mother. After the death of her mother client remain sad and feels loneliness.

1.5 Family History

The client parents’ marriage was arranged. Her parent’s relationships was not good. Her father

was a cruel person and divorced her wife when client is only two years old. The client is only

one child and has no siblings. After divorce the client mother came to her parents’ home with her

daughter. Her mother start job in a garments factory for the better future of client. The client

grandparents were died before client birth. Client and her mother lived her grandparents’ house

with client aunt and uncle. Her aunt and uncle is un-married. Her aunt is also working in

garments factory with her mother but her uncle is jobless. After the death of client mother her

aunt look after the client and help her in client work. But her jobless uncle often beat the client

and her aunt. He often physically and emotionally abuse the client. Due to this abuse client is

afraid from her uncle.

1.6 Personal History

1.6.1 Birth and Early Childhood

She said she wasthe first and only child of her parents. Her mother was very happy but

her father was not happy on client birth. She was born by normal delivery at home in Sialkot.

She was totally fine and pretty at her childhood. She starts eating by her own hands at the age of

4. She start crawling and sitting at the 1.5 year, talking and walking at the age of 2 and she say

first word “mama”. She was very talkative and naughty in her childhood. She fell hesitation from

meeting strange peoples. Even once she had fever because of fear of some strange person. She
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speak in sleep. Once blood comes out from her teeth when she fells down from the roof. She

reported that she had a pleasant childhood but she often remember her father.

1.6.2 Educational history

Client had started his schooling at the age of 4 years. She had interest in studies. She got

positions in school. She had good relationship with teachers and got good result in all classes.

She did not participated in any kind of extra-curricular activities in school due to lack of

confidence. She had few friends in school, 2 friends are close while there are almost ten

members in their class group. She is reading Quran and she has interest in Islamic education

1.6.3 Academic History

She said that I could read Urdu easily but face some problems in English. Her favorite

subject is science. She was good at drawings as she also attend drawing classes. She remains

position holder till 5th class. Her academy teacher helps her in school work. But after the death of

her mother she is not satisfied with her academic performance.

1.6.4 Social History

Client said that he do not like to meet new people and only likes to play small games as

hide and seek which she had played with friends and cousin’s in childhood. She fell hesitation

from meeting strange peoples. Even once she had fever because of fear of some strange person.

She is afraid from extra questioning of unknown peoples. She does not like social activities and

never had a close friend. She had visited Lahore in childhood but now from a long time she

never went far away from their city. She has 2 friends and name of her best friend are juvaria and
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gulshan.She does not share her problems with her friends but her friends help her when she need

the help of her friends.

1.6.5 Sexual History

The client reached at the age of puberty when she was twelve years old six month after

hermother death. Her reaction towards it was quite optimistic; she was satisfied by her look and

physical changes. She thought that now she becomes a woman.

1.7 Premorbid personality

Before the death of her mother the client life is free from tensions. She was able to pay

her full attention in her studies. Her mood was happy and enjoy her life. Her mother death brings

sadness in her life.

1.8 Psychological Assessment

The psychological assessment of the client was done at two levels which includes informal and

formal assessment.

1.8.1 Informal Psychological Assessment

Informal assessment was done by following

 Interview

 Mental Status Examination (MSE)

Interview.Interview plays an important role to gather information. Interview was conducted

to obtain comprehensive information of client i.e. family history, educational history, early

developmental history, marital history, sexual history etc. It was ensures that the information will
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be kept confidential and it will be used for educational purposes. Client’s informant was also

interviewed.

Mental Status Examination (MSE).

 Speech and language

 Content: Her content of speech seemed to be normal with accurate answering of all

questions. Form: She spoke in average and serious tone.

 Mood: The client seemed to be with normal mood. But she became sad and shade tears

when she talk about her mother.

 Perception

 Visual Perception: The client's visual perception seemed to be well. She can easily read

and understand the things. She was reading her school books before I meet her.

 Auditory Perception: She was having a sharp auditory perception. She was able to

understand the instructions given to him.

 Motor Assessment

 Gross Motor Assessment: Gross motor activities of client seemed to be fine. He could

walk and run. She also plays different games her break time.

 Fine Motor Assessment: Fine motor activities were also good. She is right handed. She

holds different things properly.

 Vocabulary: The client’s vocabulary of words was good. She was able to spell different

words as compare to her grade. Her vocabulary for Urdu is better as compare to English.

 Obsessions and compulsions: The client did not report any thoughts which show

obsessions or compulsions.
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 Attention: The Clients attention and concentration seemed to be good. But she reported

that she face attention divert problems after the death of her mother. She remained

attentive during the whole session and answers all questions attentively.

 Memory

 Short Term Memory: She was able to recall things properly. She tells me exactly the

numbers which I have tell her in the start of session.

 Long Term Memory: The client’s long term memory was good. She can recall her

address, Date of birth and childhood memories.

 Recent memory: The client tell me that what she eat yesterday in breakfast and dinner.

 Remote memory: her remote memory was perhaps so good because when I asked her

about principal of school name, she answer me “Madam Raheela”. When I asked her

about institution in which shestudy she answers me correctly.

 Orientation: She tells me exactly about time, date and name of their school principle.

This shows that orientation of time place person was good. She could report the time

exactly.

 Insight and judgment: When I asked client that if there is some fire in room then what

will your reaction then she answer that she will pour water and inform someone. When I

asked client that if there is some broken glass then what should do? She answers that it

should be remove carefully.When I asked client that what she plan to do for betterment of

her sad mood then she tell me that she try to involve in activities that make her mood

happy.

 Intellectual and general knowledge: Her general knowledge was good. She tells me

correctly about weeks in hour, provinces in Pakistan and colures in the flag of Pakistan.
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 Thought content: When the client was sad she think that “why this happen to me?” she

thinks most of the time about her mother.

 General appearance and Behavior: The client has normal gait and poster. She was not

too lean. She wears simple uniform without any jewelry. Her facial expressions are

average. She has good eye contact and her attitude towards counselor is good.

 Level of consciousness: The client is fully alert and gave all the answers of questions.

 Though process: Her though process was linear and logical. She was clear and not beat

about the bush. There is no loss association, racing, blocking thoughts or neologism.

 Depersonalization / derealization: The client never feels herself unreal. She never

thinks that she is in another world.

Symptoms rating. The client’s and the informant’s ratings of the symptoms from 0 – 10 in order

of the severity

symptoms Client Rating

Depression 9

Loneliness 9

Headache 8

Difficulty in study 7

_____________________________________________________________________________
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These symptoms ratings showed the score of client in depression, loneliness, headache and

difficulty in study.

1.8.2 Formal Psychological Assessment

In formal Psychological Assessment different standardized tests are administered to the client to

depict a clear picture of client's problem.

 CDI(Children’s depression inventory)

 PLS(Perceived loneliness scale)

 RISB (Rotter Incomplete Sentence Blank)

Rotter Incomplete Sentence Blank (RISB) Report

Test Material

Test comprises of 40 incomplete sentences. Each statement is provided with a stimulus

word/words. Rotter Incomplete Sentence Blank (Rotter & Rafferty, 1950)was used to assess the

adjustment level of the subject.

Test Administration

The semi projective Psychological Test (RISB)was administered on November 7, 2018 in

school class room. The temperature of environment was normal. The center was free from any

distraction. The subject was sitting comfortably. Before starting the test the instructions were

given according to manual. The necessary material was provided to complete the test.

Behavioral Observation
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The client feel hesitation because she can't write english well. She is a little anxious. But

she tries her best to attempt all questions.

Time taken: 25 minutes

Results

Quantitative Analysis

The test is quantitatively and qualitatively scored. Quantitative scoring is as follows;

Table 1

Table 1 showing the scores of the subject on RISB

Response Categories Corresponding Score # of Items in Categories Obtained score

Conflicts
C3 6 11 66
C2 5 9 45
C1 4 3 12
Total conflicts score 123
Neutral 3 6 18
Positives
P1 2 4 8
P2 1 6 6
P3 0 1 0
Total positive 14

Grand Total 155

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Obtained Score=155

Cut-off score=135

Qualitative Analysis

RISB administered on Miss M.T shows different responses on every item of the test. This

test expresses the participant’s inner feelings. The test shows three types of reactions in

correspond to items. These are neutral, positive and conflict behaviors. The subject scored 155

on RISB, since the score obtained is above the cutoff point this shows that the person is not

adjusted in her life. And this score show that client personality is maladjusted.

The score obtained for positive responses is 14 statements .The conflict responses

statements attained by subject are having a score of 123 .Test responses also show that client

face difficulties in daily life. Most of her statements were about her problems in life.

Conclusion

Participant scored 155 that lies above cut off point and shows that client personality is

maladjusted. The participant is maladjusted and analyzed on the whole by the score.

CDI (Children’s depression inventory)

Test Material

Test comprises of 27 items. It is use for depression measurement of children.

Test Administration
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It is five factor scale that use to measure child depression .In CDI each item is consist of

3 responses and client are directed to choose one response who is match with client personality.

Behavioral Observation

The test taking attitude of the subject was highly appreciated due to his pleasant and

interested attitude. The test taker was very comfortable and she consume 30 minutes in

completing the test. She did not hesitate or showed any problem in understanding the

instructions. But in some items she feel difficulty in understanding. According to his reported

feelings, the client was eager and curious to attempt the test. She was interested in the statements

and keenly completed all the stems.

Results

Quantitative Analysis

The test is quantitatively and qualitatively scored. Quantitative scoring is as follows;

Table 2

Table 1 showing the scores of the subject on CDI

No. Scales Raw Scores T Scores Percentile

1 Total CDI Score 26 76 98
2 ScaleATotal(NegativeMood) 7 75 >97
3 ScaleBTotal(Interp.Problems 2 64 95

)
4 ScaleC Total(Ineffectiveness) 5 74 >97
5 Scale D Total (Anhedonia) 9 71 98
6 Scale E Total (Negative Self- 3 58 89
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Esteem)

Qualitative Analysis

CDI administered on Miss M.T shows different responses on every item of the test. This

test expresses the participant’s depression level. The total CDI score shows client’s depression

level is very much above average. Her score on negative self-esteem factor above average and

Interp.problem is slightly above average. Her score on negative mood factor and anhedonia

factor is very much above average.

Conclusion

The client score on CDI shows high level of depression in client.

Perceived Loneliness Scale(L-Scale)

Loneliness scale is a unidimensionalself-report research tool which gives holistic estimate

of loneliness. It is five point Likert scale .the maximum and minimum scores range is 36 to 180.

High score is to be interpret high loneliness and low score interpret low loneliness.

Test Administration

This test was administer on client in comfortable environment. The client did not show

any kind of hesitation during administration. She was curious about the result of test.

Table 3
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No Client score on Perceived Loneliness Scale

1 142

Qualitative analysis:

The client score on perceived loneliness scale is 142. The client results shows that client

perceived loneliness at moderate level. Which shows that client seems herself alone in life.

Problem identification

The client was facing problems

 After death of her mother

 After her uncle physical abuse

 Problem in study

As a result now she feels

 Headache

 Loneliness

 Sadness

 Attention divert

1.9 Case Formulation

The client is a student. She is facing problem after the death of her mother. Her mother is only

one who was playing the role of both father and mother for client. And client can share her

problems with her mother. After the death of her mother she feel loneliness and become sad. She
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often depressed after her mother death. She feels helpless when she face difficult situation and

seems her alone. Although her aunt help her but her uncle physically and emotionally abuse

increase her sadness. Brent, Melhem, Donohoe,& Walker,(2009) conducted a study on the

incidence and course of depression in bereaved youth 21 months after the loss of a parent to

suicide, accident, or sudden natural death. In this stud 176 participants were taken whose ages 7–

25, of parents who died by suicide, accident, or sudden natural death. They were assessed 9 and

21 months after the death, along with 168 nonbereaved subjects. Major depression and alcohol or

substance abuse 21 months after the parent’s death were more common among bereaved youth

than among comparison subjects. Youth with parental suicide had a higher incidence of

depression than those bereaved by sudden natural death. Bereavement and a past history of

depression increased depression risk in the 9 months following the death, which increased

depression risk between 9 and 21 months. Losing a mother, blaming others, low self-esteem,

negative coping, and complicated grief were associated with depression in the second year.Youth

who lose a parent, especially through suicide, are vulnerable to depression and alcohol or

substance abuse during the second year after the loss. Depression risk in the second year is

mediated by the increased incidence of depression within the first 9 months. Another study was

conducted by Brent, Melhem, Masten, Porta,& Payne, (2012) on Longitudinal effects of parental

bereavement on adolescent developmental competence. This longitudinal study reports on 126

youth bereaved by sudden parental death (suicide, accident, or natural death) and 116

demographically similar no bereaved controls assessed at 9, 21, 33, and 62 months after parental

death, and at comparable times in controls. Half were female The bereaved and no bereaved

groups were compared using univariate and multivariate statistics, including path analyses. On

univariate analyses, bereaved youth had more difficulties at work, less well-elaborated plans for
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career development, lower peer attachment, and diminished educational aspirations. Children

who lost a parent to sudden death evidenced lower competence in work, peer relations, career

planning, and educational aspirations, primarily mediated by the impact of bereavement on child

and parental functioning and on family climate. Murphy, (1987) conducted his research study on

parental death in childhood and loneliness in young adults. This was a descriptive, correlational

study that was conducted to determine the relationship between self-esteem and reported

mourning behavior as it pertains to loneliness in young adults who, as children, had experienced

parental death. A sample of 184 males and females between the ages of eighteen and twenty-five

years completed the four questionnaires that were the research instruments. Data were analyzed

using hierarchical multiple regression and Pearson product-moment correlation coefficients.

Analysis of the data revealed that self-esteem was the single best predictor of loneliness and that

reported mourning behaviors significantly added to the prediction of variance in loneliness.

1.10 Management Plan

The following management plan was intended to help the client to improve his level of

Functioning related to his problem.

Short Term Goals

 To reduce the level of depression experienced by the client due to her mother death

 Help client to think less about her uncle physical abuse

Long Term Goals

 Enable client to continue these short term goals

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 Enable client to overcome her study issues.

The following interventions may be used to help the client.

1.10.1 Psycho-education .Psycho-education is an educative method aimed to provide necessary

information and training to families with psychologically ill persons to work together with

mental health professionals as part of an overall clinical treatment plan for their ill family

members. Psycho-education has been emerged as an effective adjunctive treatment which can

significantly improve the level of understanding of people about mental disorders, ensuring

active participation of both clients and their caregivers in treatment as well as make psychiatric

treatment acceptable to mentally ill people and their caregivers In a nutshell Psycho-education’s

goal is to offer education and therapeutic strategies to improve the quality of life for the family

while decreasing the possibility of relapse for the client (Bhattacharjee, et al., 2011).

1.10.2 Supportive Therapy. Supportive therapy is something believes to be provided to every

patient taking antidepressant medication. Many doctors and health workers are trained to conduct

supportive therapy but the essence of the approach is the provision of comfort, empathy,

reassurance and advice. It’s the immediacy of everyday pressures and troubles that supportive

therapists work with. There’s no attempt to analyze unconscious mechanisms and very often the

therapist will try to establish the bigger picture by finding out more from family and friends,

where this is appropriate. In this, therapist focuses on the positive aspects of treatment. They

inform patients about the nature and likely course of their depression, how to manage and adjust

to it (Kinnard, 2013). So in this case client will be helped regarding her mood problems, the way

to cope with these symptoms and help her to cope with her sadness.
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1.10.3 Individual Psychotherapy. Formal psychotherapy is seldom necessary in the isolated

stress response or Adjustment Disorder. Supportive psychotherapy, with an emphasis on the here

and now, is usually sufficient. Usually all that is required is crisis intervention, brief counseling,

and education Interpersonal approaches include psycho-education about the patient's role, a here

and now frame work, formulation of the problems from an interpersonal perspective, exploration

of options for changing dysfunctional behavior pattern will Help the client to be more adaptive

and social.

1.10.4 Activity scheduling. An Activity Schedule is a written plan of a client’s daily activities.

The client and therapist schedule activities for most hours of each day and often incorporates

those activities too which the client finds pleasurable. The activity schedule provides clients a

sense of direction and control (Leahy, 2003). This technique will be helpful for the client

problem “lack of interest” in daily activities. With this client, therapist will schedule an all day

activities so that she will be able to give more time for science.

1.10.5 Behavioral Counseling. Differential Reinforcement of Incompatible Behaviors can be

used to make the client responsive, attentive and motivate him to talk rather than to be mute and

simply laying down all the day. Because it is the best strategy for decelerating undesirable

behaviors is to reinforce acceleration target behaviors that are incompatible with them (Spiegler,

1998). In this current she can either speak or be quiet so this problem can be handled with this

mentioned technique.

1.10.6 Problem solving. Problem-solving therapy refers to a psychological treatment that helps

to teach you to effectively manage the negative effects of stressful events that can occur in life.
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Problem-solving therapy can provide training in adaptive problem-solving skills as a means of

better resolving and/or coping with stressful problems.

Such skills include:

• Making effective decisions.

• Generating creative means of dealing with problems.

• Accurately identifying barriers to reaching one’s goals. (American Psychological Association,

2013) .This will be helpful for client in teaching him to deal with in making exact and clear

decision either he want to live with his aunt or not. How she is going to deal with problem of

mood,attention and loneliness. How she is going to achieve these goals.

1.11 Recommendations

She should take small steps in reducing her tension

She should make new friends to remove her loneliness

She should do some productive activities wither friends to remove her depression

1.12 Limitations:

 There was no proper area for counseling and assessment of client and the place where

client sat was distracting.

 Time was very short for getting in depth history from the client.
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References

American Psychological Association. (2013). Specialty guidelines for forensic psychology. The

American Psychologist, 68(1), 7.

Brent, D., Melhem, N., Donohoe, M. B., & Walker, M. (2009). The incidence and course of depression

in bereaved youth 21 months after the loss of a parent to suicide, accident, or sudden natural

death. American Journal of Psychiatry, 166(7), 786-794.

Brent, D. A., Melhem, N. M., Masten, A. S., Porta, G., & Payne, M. W. (2012). Longitudinal effects of

parental bereavement on adolescent developmental competence. Journal of Clinical Child &

Adolescent Psychology, 41(6), 778-791.

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Boex, J. R., & Leahy, P. J. (2003). Understanding residents’ work: moving beyond counting hours to

assessing educational value. Academic Medicine, 78(9), 939-944.

Kinnard, J. N. (2013). Imaging wisdom: seeing and knowing in the art of

Indian Buddhism. Routledge.

Murphy, P. A. (1987). Parental death in childhood and loneliness in young adults. Omega-Journal of

Death and Dying, 17(3), 219-228.

Rapalino, O., Lazarov-Spiegler, O., Agranov, E., Velan, G. J., Yoles, E., Fraidakis, M., ... & Hadani, M.

(1998). Implantation of stimulated homologous macrophages results in partial recovery of

paraplegic rats. Nature medicine, 4(7), 814.