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Counseling Psychology
Table of Contents
Presenting Complaints 6
Family History 7
Personal history 8
Premorbid Personality 10
Identification of Problem 16
Management plan 19
References 24
Appendices
Bio Data
Name: T.A
Age: 13 Years
Gender: Male
Religion: Islam
Informant: Father
Presenting Complaints
According to Client
The client reported that following symptoms were present
I get very angry whenever I’m not able to do my own work. (six months)
Children make my fun when they see m hand in the school. (six months)
I don’t want to go out of the home because everyone watches me weirdly. (four months)
He feels that everyone make fun of his hand. He goes outside the house for lesser time. (six months)
Family History
The client belonged to middle class family. The client lived in a joint family system with his parents, his Uncle and aunts. His father A.M was
35 years old and driving an Auto Rakshaw. The client had a satisfactory relationship with his father. According to client his father was very
religious and also takes him to mosque at the time of prayers. His father always taught him to differentiate between right and wrong. His
father helped him in his studies and had not allowed him to take tuition instead he personally sits with him to get his problems solved. He
also played with him in his leisure time. His father played cricket and football with him on Sunday. His father tries his best to keep their family
happy. His father worked hard to make money for their family. According to client his father loved him a lot and always tried to cheer him up
when he was in sad mood. His father always taught him good values and not spoiled him by bought him all the things that he wanted. The
client had a very good relationship with his father as he discussed everything with him without hesitation.
The client’s mother was N.A and she was 30 years old. She was a housewife. The client had satisfactory relationship with his mother. He can
talk to her about his problems he had in his life and in school. He talked to her because she listened him and gave good advises to him. His
mother cooked his favorite food for him when he came home from school. His mother was very caring and loving and helped him in doing his
homework. According to client her mother taught him how to eat healthy food and dress himself, to how to react to the situation. His mother
taught him little things as how to tie his shoes and to be polite and respectful to adults. The relationship of client’s parents was satisfactory as
they have mutual understanding.
He had three sisters one was 16, 15 years old and youngest one was 7 years old and his brother was 5 years old. He had a satisfactory
relationship with them. He played with them in his free time. He also quarreled with them during playing. He had also very good relationship
with his cousins, uncle and aunt. They loved him very much because he was the first born child at their home. They always cared him and
taught him good manners. The client was very obedient of his parents and uncles and aunts. The home environment of client was very good
all the problems were solved by mutual discussions.
Personal History
Birth and Early Development
According to client’s mother client was born in hospital and his birth was normal. All the developmental milestones were reported to be
achieved at appropriate age. No neurotic traits were reported. The client was very healthy at the time of birth. The client started sitting with
the help of support at the age of approximately 5 month and started standing at the age of 9 month. According to informant the client had
some problem in speech and started complete talking at the age of approximately 3-4 years. The client had not any problem in eating and
started eating solid food at the age of approximately 5 month. The client had normal sleep patterns in his childhood. His mother did not face
any problem during pregnancy or at the time of birth. No history of smoking or alcohol use was present. There were no prenatal or postnatal
complications reported. No physiological illness, psychiatric disorder or major injury was reported in the client.
Educational History
The client started his studies the age of 5 years. As his father reported that he was a very bright student in his class he always got good
grades in all subjects. Mathematics was his favorite subjects. But after that incident he mostly missed his classes because he felt humiliated
when his class fellows made fun of his hand and that’s why his academic performance decreases with time. His parents and teachers paid
full attention on him and helped him in studies. At home he studied under the supervision of his parents.
Psychological Assessment
The psychological assessment was carried out at two different level
The informal assessment included mental state examination, symptom checklist and formal assessment included Child Depression Inventory
(CDI), The Self Image Profile (SIP-C) and The Adolescent Anger Rating Scale (AARS).
Informal Assessment
Mental State Examination.
General Appearance and Behavior
The client was well and season appropriate dressed. He 13 years old boy with average height. He seemed to be fragile and weak apparently.
His shoes was neat and clean. He combed his hair well. His eye contact was frequent He was not comfortable at first but when confidentiality
was assured he easily explained all issues. He kept his hands and legs in a comfortable posture throughout the sitting.
Client reported that he do not know why he get angry on certain things without any reason.
He said that he has been living a purposeless life. Which has no direction. Client’s answers showed that he has inadequate thought content.
Language Assessment
Receptive Speech
The client’s receptive speech seemed to be good. It was relevant.
He could easily tell the meaning of home, sky and balloon.
Expressive Speech
The client’s expressive speech seemed to be Excellent. Although at starting of assessment he was hesitant but after some motivation it
seemed that he had no difficulty in expressing himself in speech.
Motor Assessment
Gross Motor Assessment
Client’s gross motor activities seemed to be fine. He could walk, run and climb stairs easily and did not find any difficulty to
handle these skills.
Fine Motor Assessment
Client’s fine motor activities also seemed to be fine. He is right handed. He was able to hold pencil the correct way. He can
cut things, use scissors properly with other hand.
Cognitive Assessment
General Fund of Knowledge
The client seemed to be having good general fund of knowledge. He responded to questions correctly. Following questions were asked by
the client to access the general fund of knowledge.
Abstract Reasoning
The client’s abstract reasoning seemed to be average. He could easily explain the similarities and differences between things e.g book and
laptop, Tiger and Leopard.
Symptoms Ratings
The ratings of the symptoms of the client were taken from both the client and the informant who was his father in this case. These ratings
were made out of 10 in the increasing order of the severity.
Table. 1
The client’s and the informant’s ratings of the symptoms from 0 – 10 in order of the severity
Symptoms Client’s ratings Informant’s ratings Mean
Sleep disturbances 8 9 8.5
Depression 7 8 7.5
Self image 8 8 8
Anger 8 9 8.5
___________________________________________________________________________
2. The Self Image Profiles for Children (SIP-C) and Adolescents (SIP-A)
Test Administration
Child Depression Inventory (CDI)was administered on the client on Thursday, May 5, 2015, in a well and ventilated room of the hospital. The
client was sitting on a chair, behind the table and the instructions were given to him according to the manual. The difficult items or their
responses were repeated again for his convenience when he asked for, so that he could comprehend the test easily. He took her 10 minutes
to complete the test.
Quantitative Analysis
Table 1.The client’s total raw score, range and remark on CDI
Total Raw
T score Cut off Remark
Score
Qualitative Analysis
The client completed the CDI in ten minutes and obtained the raw score of 05 which means that his t-score was 56 which suggests slightly
above average depression. The CDI was able to screen out slightly above average depression in the client. The CDI was able to screen out
depression in the client. The results of the test applied on the client placed him among the category of slightly above average depressed
children individuals. His results are consistent with the symptoms he was experiencing.
The Self Image Profiles for Children (SIP-C) and Adolescents (SIP-A)
The Butler Self Image Profiles (SIP) is brief self-report measures that provide a visual display of both self-image and self-esteem. There are
two forms; the SIP-C for children aged 7-11 years and the SIP-A for adolescents aged 12-16 years. Both of the forms have different item
content appropriate for respective age levels, but an identical format and scoring procedure. The SIP taps the individual’s theory of self. Both
the SIP-C and SIP-A consists of familiar self-descriptions; 12 of a positive nature, 12 with a negative slant and one neutral item. All self-
descriptions are words or short statements generated by children and adolescents (Butler, 2001).
Test Administration
The Beck Depression Inventory (BDI)administered on the client on, march, 2017, in a well-lit and ventilated room of the hospital. The room
was peaceful and noise free and there was not any distraction. It was not crowded and the client was made to sit in a comfortable chair with
a desk in front of it, placed on one side of the room. The client was sitting on a chair, behind the table and the instructions were given to him
according to the manual. The client was provided with a copy of the Beck Depression Inventory, so that she could follow along and was
asked to report his feelings for the past two weeks, including today. He 5 minutes to complete the test.
Quantitative analysis
Table 1. The scores of The Self-Image Profile
Cut
Responses Items no. Scores Description
off
low positive
SI+VE Sum of items 1-12 33 35
self-image
sum of discrepancy
SE 87 76 Cause of concern
scores
Qualitative Analysis
The client obtained a raw score of positive self-image 33 which was lower than the cut off score which indicated that the client low positive
self-image and it was a matter of concern. The raw score of negative self-image was 52 which were equal to the cut off scores and it
depicted that the client had high negative self-image. The raw score of self-esteem was 87 demonstrated that the self-esteem of client was
very low and it was matter of concern. The high score of self-esteem scale reflect significant difference between “what I am”, “what I like to
be” and thus is indicative of low self-esteem. This score may indicate that how much the subject does not like what already he is Self-Image
Profile was able to screen out positive self-image toward oneself, negative feeling toward one’s own self and self-esteem of one’s self. These
results are consistent with his background as the client was taken from the hospital with low self-esteem.
Test Administration
The adolescent anger rating scale (AARS) was administered on the client on Thursday, May 5, 2015, in a well lit and ventilated room of the
hospital. The room was peaceful and noise free and there was no distraction. The client was made to sit comfortably in his bed. The
instructions were given to him according to the manual. The test was orally administered to the client. The client was provided with a copy of
the (AARS), so that he could follow along. The difficult items or their responses were repeated again for his convenience when he asked for,
so that he could comprehend the test easily. He took 20 minutes to complete the test.
Qualitative Analysis
Average Level
IA 33 53 73
of anger
Average Level
RA 20 57 78
of anger
Average Level
AC 28 46 40
of anger
Qualitative Analysis
The client obtained the raw score of 90 which t score was 55 and percentile was 73. The results of the test showed that client had average
level of anger.
Identification of Problem
The client was taken from the Jinnah Hospital with complaints of sadness, anger, sleep disturbances, poor academics and low self esteem.
The client had an accident eight months before as his left hand was seriously injured by chaff cutter machine. When the client was taken to
hospital his hand was completely damaged and doctors had to amputee his hand. The client was feeling depress on losing his hand as it was
badly effecting his body image. The client felt humiliated when his school fellows made fun of his amputee hand. The client was angry that
why this accident was happened to him. The client was very upset that he was not able to do his work by himself.
Case Formulation
The client was taken from the hospital with the problem with his hand. His hand was completely damaged in that accident and doctors had to
amputee his hand. The client worried and depress about his condition because he had to face difficulty in his daily life activities. The
psychological assessment was carried out on informal as well as formal level. The informal assessment included mental state examination
and formal assessment included Child Depression Inventory (CDI), The Self Image Profile (SIP-C) and The Adolescent Anger Rating Scale
(AARS). The results of the tests indicated that client had slightly above average depression, had low lev el of positive self image and high
negative self image and average level of anger,
The word amputation is derived from the Latin amputare, “to cut away”, from ambi- (“about”, “around”) and putare (“to prune”). Amputation is
the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger. There are many reasons an amputation
may be necessary. The most common is poor circulation because of damage or narrowing of the arteries, called peripheral arterial disease.
Other causes for amputation may include: severe injury (from a vehicle accident or serious burn, for example), cancerous tumor in the bone
or muscle of the limb and serious infection that does not get better with antibiotics or other treatment etc (McNaughty, 2015). In clients case
he was seriously injured by the chaff cutter machine and when he was taken to hospital there was poor circulation of blood in hand and
doctors had to amputee his hand.
Most patients who lose a limb as a result of traumatic or surgical procedures encounter a series of complex psychological responses
(Cansever et al 2003). Many people successfully use these responses to adjust to amputation, but others develop psychiatric symptoms
(Frank et al 1984). Shula and colleagues (1982) and Frierson and Lippmann (1987) note that as many as 50% of all amputees require some
sort of psychological intervention, and Shula and colleagues (1982) reported that depression is the most common psychological reaction
among amputees. The client was feeling depress on his condition because he had lost his body part and he was not able to perform his
tasks easily by himself.
According to research by Kindon and Pearce (1982), Kohl (1984), and Cansever and colleagues (2003), psychological reactions to
amputation depend on a number of factors, which include age and sex, type and level of amputation, lifelong patterns of coping with stress,
value placed on the lost limb, and expectations from the rehabilitation program. Kohl (1984) added that the individuals affected by the
traumatic loss of a limb are required to face a redefined body and self as well as a new reality. The client had to face problem regarding his
self image as the client was in the age of pre adolescence but children adapt well to the loss of function and manipulate prostheses and other
limbs with great agility. They are particularly sensitive to peer acceptance and rejection. The client was also worried that how he will
participate in physical activities that required both hands as cricket etc.
The loss of limb through accident is a tremendous shock. Unless your child is very young, they will feel the same emotions as adult
amputees – grief, depression and anger. In addition, children often feel guilt for bringing pain and problems to their parents (Ratto, 2014). In
client’s case he was very angry that why that accident was happened to him and it caused problems for him and his family.
Management Plan
Management plan is designed to help the client to resolve his problems and to return his back to the community sound and healthy. Several
therapeutic interventions are designed for this purpose to be used with the client. Some of the therapies that can be used for the client who is
suffering from depression, problems of anger and negative self-image are as follows
Supportive work
Psycho education
Behavior Therapy
Family Therapy
Summary of Therapeutic Interventions
The client can be helped by using a number of therapeutic interventions, some of which are as follows:
Supportive work
Supportive psychotherapy is the attempt by a therapist by any practical means whatever to help patients deal with their emotional distress
and problems in living. It includes comforting, advising, encouraging, reassuring, and mostly listening, attentively and sympathetically. The
therapist provides an emotional outlet, the chance for patients to express themselves and be themselves. Also the therapist may inform
patients about their illness and about how to manage it and how to adjust to it. Over the course of treatment he may have to intercede on a
patient’s behalf with various authorities, including schools and social agencies, and with the patient’s family- indeed, with all of those with
whom the patient may be contending (Neuman, 2013).
Psycho education
Psycho education refers to the education offered to people who live with a psychological disturbance. Frequently Psycho educational training
involves clients with complaints of depression, anxiety, hopelessness, loneliness, eating problems, and sleep problems etc. The main
purpose of psycho education is to educate the client about his condition and also its management to help the client to deal with the problem
by himself. The client needs to be educated about his problems and what factors are affecting on it and how he can control it. The client
should be educated about the importance of self-management and how he can cooperate with his psychologist to make him better. The
client’s family also needs to be educated to support him when he needed. Amputation is a triple threat. It involves loss of function, loss of
sensation and loss of self-image so it is very important to deal with it. First of all the client will gain insight about the aspects of his problem
then he will be able to easily deal with it. The theory is, with better knowledge the client has of her illness, the better the client can live with
her condition. Psycho education can be provided to the client and family members together or separately (Hudak& Dougherty, 2011).
Behavioral Therapy
Contingency Contract
Contingency Contracting is a type of intervention that is used to increase desirable behaviors or decrease undesirable ones. A contingency
contract may be entered into by a teacher and student, a parent and child, or a therapist and client. It specifies the target behavior, the
conditions under which the behavior will occur, and the benefits or consequences that come with meeting or failing to meet the target. This
technique will be used to change the behavior of client during studies to motivate him to work hard. This technique will also be used to
decrease the anger level in client.
Exercise
Exercise, particularly aerobic exercise, is good for both sleep and overall health and should be encouraged. Avoid stimulating exercise in the
evening (do this at least 5 hours before bedtime).
Bedtime Ritual
Perform relaxing activities in the hour before bedtime. Make sure your sleeping environment is as comfortable as possible, paying attention
to temperature, noise, and light. Do not eat a heavy meal just before bedtime, although a light snack might help induce drowsiness. It is
sometimes helpful to place paper and pen by the bedside. If you find yourself worrying about completing or remembering a task the next
day, write it down and let it go.
During the night
If you awaken and find you can’t get back to sleep, arise from bed and do quiet, relaxing activities until you are drowsy. Then return to bed.
Place clocks so that the time is not visible from the bed (Bazil, 2015).
Behavior Activation
As a treatment for depression and other mood disorders, behavioral activation is based on the theory that, as individuals become depressed,
they tend to engage in increasing avoidance and isolation, which serves to maintain or worsen their symptoms. The theory holds that not
enough environmental reinforcement or too much environmental punishment can contribute to depression. So, the treatment tends to
increase environmental reinforcement and reduce punishment. The goal of treatment, therefore, is to work with depressed individuals to
gradually decrease their avoidance and isolation and increase their engagement in activities that have been shown to improve mood. Many
times, this includes activities that they enjoyed before becoming depressed, activities related to their values or even everyday items that get
pushed aside such as:
Exercising, going out to dinner, improving relationships with their family members, working toward specific work-related goals, learning new
skills and activities, Showering regularly and completing household chores etc. this technique will be used for client to decrease his
depression level by involving him in different activities (Leahey, 2003).
Activity Schedule
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
(Leahey, 2003).
Cognitive Rehabilitation
The objective of this technique is to improve cognitive functions of patient, reduce the symptoms and enhance the patient’s adaptive
functioning in the real world. It focuses on memory, attention and executive functions (Seligman, Walker & Rosenhan, 2001, p. 462). It will
enhance the memory, attention, concentration, problem solving skills and executive functions of the client.
Philosophical Disputes
The philosophical approach addresses a life satisfaction issue. Often the client will have been too focused on the identified problem that he
has lost perspective on the other areas of his life. The problem has subsequently become the defining element of the client’s existence. It
can be helpful to do some reality testing about other aspects of their life (Ellis & Maclaren, 1998).
Anger Management
Relaxation Exercise
Psychologists train patients in a technique called “progressive relaxation” until they’re able to relax simply by thinking of a particular word or
image. Psychologists then ask patients to spend a minute or two thinking intensely about a situation that makes them excessively angry,
such as other drivers going too slow. Psychologists then help patients relax. Psychologists and patients practice this sequence over and over
again. After about eight sessions, patients are typically able to relax on their own (Stearns & Stearns, 1989).
Listing of advantages and disadvantages of anger, distraction from negative thoughts, identifying bodily symptoms associated with anger,
using positive statements and identifying positive solutions etc will also be used to treat anger.
Once the client learn to recognize what stage of anger they are in, they can utilize coping strategies learned in anger management programs
to stop the progression of their emotions before they reach red. Anger is a complicated and overwhelming emotion, but using a traffic light for
anger management allows client to visualize their anger and the steps necessary for controlling their reaction to angry emotions (Ketcham,
2015).
Family Therapy
All human beings require a support system throughout life in order to maintain emotional health. However, not all are so blessed, and many
find themselves transiently or permanently in state of isolation. Single and widowed individuals suffer more psychological distress and
difficulty in adapting to amputation than do those who are married and have a family. Particularly helpful in adjustment of the adult amputee
is the presence of a supportive partner who assumes a flexible approach, takes over functions when needed, cuts back when the amputee is
able to manage, but at all times maintains the amputee’s self-esteem. Parents are the major source for children and adolescent amputees
but peer acceptance beyond the family is critical in the successful adaptation of all amputees and especially children and adolescents (Racy,
2015).
Limitations
The environment of hospital was not appropriate for psychological assessment. There was not any appropriate place for conducting
assessment and the place where the assessment was carried out had many distractions which sometimes made it difficult for the client to
concentrate.
The time given to carry out the assessment was too short and it was impossible to collect the complete, detailed and in depth information
about the client in that short period of time.
No follow up session was done to see the effect of techniques that client learned in session.
Suggestions
The client and his family should accept that client’s was amputee and it takes time for him to cope with this problem a disease in which
progress is very slow so they have to work together for the treatment to work.
Client’s family should support him so that he will be able to fight with that problem.
The client and family should be prepared that it is a long term treatment for that problem so time needs for him to reach his normal
emotional state and do his tasks by himself.
There should be a proper room for carrying out the psychological assessment and intervention of the client. A place where there is no
such thing which can distract the client during assessment.
Sufficient time should be given for the rapport building and for getting the complete and comprehensive information about the client and
also for the follow up sessions.
Also Study:
Psychological Assessment Example
References;
Cansever A, Uzun O, Yildiz C, et al. Depression in men with traumatic lower part amputation: A comparison to men with surgical lower
part amputation. Mil Med. 2003;168:106–9. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
Ellis, A. &Maclaren, C. (1998). Rational emotive behavior therapy: A therapist guide. USA: Impact Publishers, Inc.
Frank RG, Kashani JH, Kashani SR, et al. Psychological response to amputation as a function of age and time since amputation. Br J
Psychiatry. 1984;144:493–7.Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
Frierson RL, Lippmann SB. Psychiatric consultation for acute amputees. Psychosomatics.1987;28:183–9 Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
Hudak, R. & Dougherty, D. (2011). Clinical obsessive-compulsive disorders in adults and children. UK: Cambridge University press
Ketcham, S. (2015). Using a Traffic Light for Anger Management. Retrieved from
http://stress.lovetoknow.com/Using_a_Traffic_Light_for_Anger_Management
Kindon D, Pearce T. In: Psychosocial Assessment and Management of the Amputee in Rehabilitative Management of the
Amputee. Banerjee S, editor. London: Williams and Wilkins; 1982. pp. 350–71.
Kohl S. The process of psychological adaptation to traumatic limb loss. In: Krueger DW, editor.Emotional Rehabilitation of Physical
Trauma and Disability. New York: SP Medical and Scientific Books; 1984. pp. 113–48.
Kohl SJ. In: Emotional Coping with Amputation in Rehabilitation Psychology: A Comprehensive Textbook. Krueger DW, editor. Rockville,
MD: Aspen; 1984. pp. 273–82.
Seligman, M. E. P., Walker, E. F., & Rosenhan, D. L. (2001). Abnormal psychology (4thed.). USA: W W Norton & Company.
Shula GD, Sahu SC, Tripathi RP, et al. A psychiatric study of amputees. Br J Psychiatry.1982; 141:50–3. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526369/
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