Case Presentation

By: Rida Zaheer

Source of referral and agency
• Client had been referred by her family and the case was taken
in Fauji Foundation Hospital Rawalpindi.

• She visited hospital along with her daughter who informed that
she feel weakness, facing lack of concentration on her daily
work, shows aggressive behavior and sometime start weeping
with disturbed sleep and poor appetite.
Demographics
• Name XYZ
• Age 42 years
• Siblings 5( 3 brothers,1 sister)
• Birth order 3rd
• Education B.ed
• Family structure Nuclear
• Marital status Married
• Occupation Housewife
• Spouse age 45 years
• Spouse edu Matric
• Children 1 daughter, 2 son
Verbatim
“Niend nahi aati sari rat kisi na kisi soch mein gum rehti
hun, kisi se bat krne ko dil nahi karta mera, rona ata rehta
hai, khana khany ka dil nai karta,pata nahi ye sab halaat
theek hongy ya nahi, ghar chalana itna mushqil hota ja
raha is ka asar bachun ki personality pr parta ja raha hai,
mera dil karta hai k mery bachy kabhi ahsas kamtri ka
shikar na hun zindagi behtr thi agar mian ko business
mein nuksan na hota is k bad sy pareshan rhne lgi hon.”
Presenting Complaints
• Hopelessness
• Insomnia
• Low energy and fatigue
• Poor concentration
• Worrying
• Poor appetite
• Crying spells
Background and History
• Client’s problem started 8 months ago, because of some
stressful events that occurred in her life. 2 year ago her
husband had a loss in business. There were financially
disturbed and there came a time when they had nothing to eat.
They suffered badly and then her husband sold all of her
jewelry to start a new business but where he invested money
that person ran away the money.

• The studies of her children were effected greatly. She became

worried that she can’t give her children a best life. After it she
diagnosis with cancer, she developed body aches as well as
her sleep became disturbed .
• Client reported that she thinks she is failed to give her
children best life, she is worthless and she cries a lot
when alone. Her eldest daughter knows of her
condition.

• Her husband is very hardworking but not educated.

Recently he has started doing a job in factory but the
package was not good but somehow they are managing
to make ends meet.
Family history
• Mrs. XYZ is a 42 years old housewife who belongs to
a middle class family. She lives in a nuclear family. Her
parents have passed away. She has three brothers and
one sister and all her siblings are married. She reported
that she doesn’t get along with them. Her husband is 45
years old and a businessman by profession, she has a
good relationship with him but since the last 8 months
her relationship with him has been disturbed due to
financial issues. She has 2 son and 1 daughter, all her
children are school going.

• There was no family history of psychological disorder.

personal history
Client’s birth was normal and without any
complications, she achieved all milestones on
time. She received education up to B.A after that
she got married but she expressed that she
wanted to study more after marriage so she had
done her B.ed after her marriage. She got married
at the age of 25. She reported that her parents in
law were strict but her husband was a loving
person but whenever her mother in law said her
anything he never take my side but after it he
apologized to me.
Premorbid personality
• A client was very friendly, talkative and social
and she used to take good care of her children
and family before the onset of the symptoms.
Diagnosis

296.33(F33.2) Major Depressive Disorder

(due to medical illness)
CASE CONCEPTUALIZATION
• Humanists believe that there are needs that are unique
to the human species. According to Maslow (1962) the
most important of these is the need for self-
actualization (achieving out potential). The self-
actualizing human being has a meaningful life.
Anything that blocks our striving to fulfil this need can
be a cause of depression. Similarly, in my client there is
not any specific aim for her life, she dreamed that her
children got good education but her financial condition
won’t allow her to do that which leads feel empty
feeling, hopeless and later on cause depression
symptoms. (McLeod, 1970, January 01)
• Brown and Harris (1978) found an increased incidence
of stressful events in the lives of depressed women but
only with regard to a particular subset of such events
those that were severe and involved long-term
consequences for the woman’s well-being such as
illness, loss of a job, and many other types of personal
adversity. The impact of a stressful event apparently
depends on the meaning that the event has for the
person. Severe events that occur (such as a child’s
health or the development of a career) are most likely
to lead to the onset of depression (Brown, 2002). As in
my client following events are when her husband has
loss in business and when she is diagnosis with
cancer(Wolejko, 1998).
PROGRESSION OF THERAPY
• 9 sessions were conducted with the client.
SESSION I
Client’s demographic details were taken,
presenting complaints and the causes that led to
the presenting complaints were noted. Client was
willing to improve her condition and was open
about the problems she was facing, so rapport
was built easily.
• SESSION II
Detailed session about the presenting
complaints, personal history, marital history,
and family history was carried out with the
client. The main goal of the session was to
provide client with the comfortable
environment to facilitate the therapeutic
process.
Client was asked to practice deep breathing
exercise.
• SESSION III
The goal of this was to conduct
psychometric assessment.
 HTP
 BDI
 BAI
• Beck depression inventory
Client has 33 score on BDI which
shows severe depression.
• Beck anxiety inventory
Client has 24 score on BAI which
shows moderate anxiety.
HTP Findings
• Fantasy
• Insecurity
• Inferiority
• Confused thinking
• Withdrawal
• Restlessness
• Failure
• Low self esteem
• Our striking
• Weak nurturing
• Anxiety
• Introversion
• dependency
• Secretive behavior
• Emptiness
• Sensitive to criticism
• SESSION IV
Following psychometric assessment was
carried out:
 RISB
 BGT
RISB
client has 165 score on RISB
BGT
• SESSION V
Psychometric assessment continued:
 TAT
The daily activity chart for the client was
also made with the consent of the client.
TAT STORIES
• SESSION VI
• Psychometric assessment continued:
 SPM
The client score lies in 50th percentile which shows she is
intellectually average.

• In this session process of therapy and client’s agreement for

participating actively in the therapy was taken. The client was
suggested that her husband had previously provided important
support to her and that a dispute had significantly contributed
to her despair and isolation. The client was given
rationalization and importance of therapy in resolving her
problem.
Session VII
• Goal:
The basic goal is to explore irrational thoughts, and apply insight
therapy (ability to acquire a new accurate awareness or comprehension about a
things or a person and also to educate her stress coping).
• After completing my assessment as, I develop a management plan for my
client to assess her personality, stressor and educate stress coping
techniques. I decided to do CBT therapy technique (cognitive
restructuring).
• I start this session again asking her about her stressor and educate her how
to cope with the stressor one by one on each stressor I apply insight
therapy which helps client to understand how events in their past are
negatively influencing their current thoughts, emotions, and behaviors, as
client reports that she has negative thought about herself she always thinks
that her life is worthless. therefore, for all those stressors I educate her to
do following things to cope with her stress.
 Maintain a positive attitude toward oneself and other members of the family (make an effort to replace
negative thought with positive one.

 When you feel angry count to 10 slowly. Repeat and count to 20 if necessary. (distract yourself).

 Take deep breaths (inhale and exhale slowly)

 Learn what trigger your anxiety then there will be 2 ways one accept that you cannot control
everything. Put your stress in perspective is it really as bad as you think? Or try to control your own
self for this engage yourself in healthy activities.

 Talk to someone, tell your friends and family (husband) you are feeling overwhelmed and let them
know how they can help you.

 Get enough sleep (when you stressed out your body need additional sleep and rest.

 Eat healthy do all this not just because of yourself also because of your family identify your strength
and weakness if you are willing then we will able to assist you. You have to work for your own self
not just because of yourself but also for your children. Close the session after repeating the points once
again and asked her to follow these points by heart.
Session VIII
Goal
The basic goal of this session is to confront, challenge and replacement of negative thoughts.

 In this session I want to reduce stress and anxiety by changing thinking of the client. For this my first
step is to calm my client by doing deep breathing relaxation exercise which I have already educate
her in the previous sessions, then identify the situations that trigger the negative mood, analyze the
client mood that what she felt during that situation. Through analyze mood I explore about client
thought because it is suggested that an easy way to distinguish mood is from thoughts. You can easily
describe mood but thoughts are more complex. Then next step will be identifying the automatic
thought. Ask the client to tell the natural reactions, you experience when you felt that mood and also
gave objective for this natural thoughts and then find contradictory objective then identify fair and
balanced thought related to that event, then it will be the time to monitor your present mood.
 During the initial sessions client said that the present illness is because of her fianacial situations and
her illness in this session, I tried to counsel my client that these problems can be treated if she
develops wellbeing and fight against her illness that can be treatable.
 I also gave my client worksheet of cognitive restructuring, in this session the technique I used to
reframe the unnecessary negative thinking and mood that reduce the quality of performance cognitive
restructuring helps to change negative or distorted thinking that lies behind the mood of the client.

Closing the session by asking client what she thinks how much this session benefits you in recovery. The
client replies that she is really feels satisfied after my every session. She said that starts to do some work to
improve their financial situation.
SESSION IX
Goal:
The basic goal of this session is overcome client inferiorities.
 Determine who you feel inferior.
 Stop worrying what other thinks and do.
 Build your self confidence.
 Surround yourself with positive people.
 Decrease absconding from your relatives.
 Set realistic goals.

Termination of the session was done. The session was terminated

with the mutual consent of the client and therapies and she was also
told to take follow ups in future if needed.
PROGNOSIS

Prognosis seems favorable because the

client had insight of her problems and was
motivated towards getting better.
Thankyou