Summary

M.S was a 21 years old male who was referred to the trainee clinical psychologist with
complaints of lack of interest, worthlessness and anxiety. Informal assessment (behavioral
observation, clinical interview, subjective ratings of the problems) and formal assessment (Mini
Mental Status Examination (MMSE), Drug Abuse Screening Test (DAST), Rotter Incomplete
Sentence Blank (RISB) and House, Tree, Person (HTP) were administered. On the basis of
formal and informal assessment, he was diagnosed with Cannabis Use Disorder, Heroine Use
Disorder and Stimulant Use Disorder. The client seems to have good prognosis. Management
plan was devised to manage his feelings of worthlessness, low self-esteem, lack of interest and
relapse prevention by using techniques of cognitive behavior therapy (CBT).
 Clinical Case Report

Identifying Information

Name M.S

Age 21

Gender Male

Status In-patient

Marital Status Unmarried

Education Upper Primary (grade 8th)

No. of sessions 7

Initial date seen 22-04-2024

Last date seen 25-06-2024

Source and Reason for Referral

The client was referred by the psychologist of Manzil e Nau to the trainee clinical
psychologist for lack of interest in activities. His symptoms as reported by him were feelings of
worthlessness, anxiety and lack of interest. Problems observed by trainee clinical psychologist
were low self-esteem, self-blaming, worthlessness and excessive details during conversation.

Presenting Complaints

Verbatim of client,

Table No: 1

Duration Presenting complaints Sr.

No
Initial Observation

The client appeared physically fit and well-groomed. His hair was neatly tied and dress was
weather appropriate. His sitting posture was normal. Eye contact was maintained throughout the
initial interaction. His voice tone was normal and speech was clear He readily engaged in
conversation.

History of Present Problem

The client reported that he felt lack of interest in everything for past 3-4 years. He liked to play
handball but he had lost interest in playing. He did not like to meet his family and cousins’
gatherings. He avoided attending any birthday party of friends. He lacked interest in taking
personal care. He stopped going to gym and did not exercise. He liked to maintain his exercises
and focus on personal care before he got addicted to drugs. Now, he did not find any pleasure in
those activities. Lack of interest in activities started 3 years after he started taking drugs. He used
to spend most of his time in arranging money and getting drugs.

Client further reported that he had anxious feelings about everything for past 4 years. He felt
anxious about getting caught by his father or uncle while taking drugs. Whenever, he promised
his parents that he will quit drugs, he felt anxious how he will manage his withdrawal symptoms.
He often loss control, used abusive language with his parents under the influence of drugs. He
felt ashamed and worry, after every time he misbehaved his parents. He often thought about his
future. Thoughts like weather he will able to manage his own business, to establish healthy
relationships with family members, to regain their trust and settle a good married life often came
in his mind.

He reported that he thought himself as a bad person and he is not capable to do anything in his
life because he had done nothing good in his life. He spent many years in addiction, caused his
parents and family in trouble. They felt ashamed whenever any person inquired them about
client’s drug taking habit. His girlfriend left him because he did not stop drugs. He felt himself a
reason of their break up. He reported that if he quite drugs at that time, his girlfriend would be
with him now, he thought himself as a bad person who even could not managed his relationship
with her.

The client reported that he started taking drugs about 7 years ago. He was in class five when he
took cannabis in a cigarette for the very first time. The client with his friends during the break
time in school, went to a park nearby his school and his friends offered him a cigarette by saying
that it has good flavor. The client revealed that he experienced blackouts and vomited after
taking that cigarette. Then, he again took cannabis next day. He continued taking cannabis for
next 8 months. He got enough pocket money to arrange cannabis for himself. During these
months, he came to know that the place (Pakka ghara) where he lived at that time, there were
some men in his street who took drugs. He approached one of those men and asked for drugs. He
took a pack of heroine which was in powder form. According to the client, he felt a warm,
tingling sensation. His speech was slurred and slower for the whole day, when he took heroine
for first time. The client reported that he experienced feelings of happiness an excitement every
time after taking heroine. He found it very interesting to remain awake for long time. He reported
that he often couldn’t sleep for 3 days due to the influence of heroin. He started taking heroine
about 3-4 times a day. Heroine was expensive as compared to cannabis as the client reported that
he used to buy 25 grams of heroin in 12000 rupees which he found quite difficult to arrange. So,
he started taking more pocket money from his parents. As he was the eldest son of the family, his
father had always given him money without asking. At that time, he took Alcohol, Cannabis and
heroin. He often took them all in one time or separately but he took heroin more among all. As
reported by the client, the highest dose of the heroin he ever had taken, caused him to stay
awaken for 6 days. He revealed that it felt pleasurable and powerful to not sleep after taking the
drugs. He thought that he can do anything he wants, no one can hurt him. Thoughts like he is
superior and other people are ordinary because he can stay awake for many days, feelings of
pleasure were experienced. After one year, he was introduced to Ice by one of his addicted
friends which was expensive than Heroin. He got 1 gram of Ice in 1000 rupees. When he
demanded more money from family, they inquired him about money and he got angry. He
thought that his family does not care about him and demanding him to give clarifications about
his money spending details. He thought they do not love him. He again shifted to heroine as it
was cheaper and it gave enough satisfactory and pleasurable effects to the client.
In 2020, his uncle saw him taking drugs with his friends. He informed his family. The Client
reported that, his mother was crying when she came to know about him taking drugs. His father
discussed all the bad consequences he may experience in future because of drugs. His younger
siblings were not informed about this. He was embarrassed at that time by seeing his family in
trouble. He decided to quit the drugs by promising his parents to not use the drugs again. He felt
severe body pains, muscle aches, fever, sweating, restlessness, irritable mood and anger after
quitting the drugs. He couldn’t manage his condition. His father took him to a doctor, who
prescribed some medicines. He felt sleepiness, blackouts after taking those medicines. He used to
sleep for hours. After two weeks, while walking to his uncle home, where he started taking
heroin, he met his addicted friend and can’t stop himself by taking a pack of heroin from him.
From that day he again started drugs. When his parents came to know, they brought him to
Manzil e Nau in 2022 for treatment. According to the client, he was not happy with his parent’s
decision to make him stay there. At that center, detoxification process was done to manage his
withdrawal symptoms. Some medicines were also given regularly. He lived for three months
there. After releasing from rehabilitation center, his parents sent him to Dubai where his cousins
lived. He lived with his cousins there. The client reported that he started taking drugs in Dubai
too. Drugs were expensive there; it was difficult for him to manage money. When, he
experienced withdrawal symptoms (body aches, headache) his cousins gave money and he
purchased drugs from a known person he met at Dubai. He tried some other new drugs named
Holder, Bonza and skunk in Dubai. He lived in Dubai for one year. When his father came to
know through his cousins that he was taking drugs in Dubai, he called him back in Pakistan. He
continued taking drugs in Pakistan. His father brought him again at Manzil e Nau in 2023. He
was in that center for last 10 months.

Back Ground Information

Personal History

The client has established a structured daily routine while living in rehabilitation
center. He wakes up between 7-8 am daily and has breakfast. After that, he watches TV, with
other fellow individuals. He has lunch then. Lunch is followed by group meetings with fellow
individuals struggling with drug addiction. The client shares his personal experience and
motivates them to prevent drugs. Afterwards, he takes rest. He often plays some games like
Luddo. At evening time, deep breathing, relaxation techniques and some other exercises like
push-ups are practiced. He has his bedtime at almost 10:00 pm. He was not inclined to religion
but in rehabilitation center he offered prayers regularly with other fellows.

The client reported that there is no history of any illness, trauma and injury in childhood. In his
childhood, he always received love and care from his parents.

Client likes to play hand ball. He likes to travel. He had visited the northern areas of Pakistan
several times during childhood with his family. He is fond of outdoor activities like hiking. He
likes to spend time with his cousins and had travelled with them many times. Exploring and
searching for new places to visit is his free time activity. He dislikes to being away from nature.

Educational History

The client started his schooling at the age of 4 years in 2007 at a private school in
Islamabad. His first day at the school was well spent as he make friends there. In grade 4, he
secured 2nd position in the class. When he moved to Sialkot with his family, he was in 5 th grade.
He took admission in City public school, Sialkot and he made new friends in class. His new
friends did not like to study. They often used to come outside the school at break time. As it was
not allowed to move outside the school premises in break time, some senior boys often go
outside by giving some money to watchman. The client and his friends also gave some money to
the watchman and went to a park nearby the school. While playing in the park, the client’s friend
brought a cigarette from his pocket and offered him by saying that try it, it has good taste. Client
accepted the offer. It was a cannabis filled cigarette and he started vomiting after taking it first
time. Then, he continued taking that cigarette daily. He gradually lost interest in studies. His
grades dropped. Teachers often complained about his poor performance in class. He preferred to
stay outside the home with friends. His mother arranged a home tutor to help him with his low
grades. He often ran away from home to play with his friends and skipped the tuitions. At the
end of the educational year of 8th grade, he quit the school before the exams. His parents insisted
to continue but he did not continue and quit in 8th grade.

Premorbid History
 The client was a well-known child in school because he had a strong social network. He
had many friends in class. He was energetic child. He was active in extracurricular activities
such as jumping and race competitions in sports and festival participations in school. He had a
close relationship with his family, especially with his father. He had a good sense of humor,
making others laugh.

Family History

The client lives in a nuclear family. He lives with his parents and his siblings. As
reported by the client, his father is 62 years old and own a clothe shop in Cantt, Sialkot. He uses
to spend almost 9-10 hours in his shop from 2:00 pm to 12:00 pm. He has completed his study
till matriculation. His father has friendly relationship with the client. The client reported that he
is closed to his father since his childhood. His father has always encouraged him to share his
problems with him. His father earned enough money to run the family expenses in a very good
manner. Client revealed that when his father got to know about him taking drugs, he asked him
all the details about the drugs. He asked him about his timings of taking drugs, how he managed
money to take drugs and all related details. The client resisted to answer and then got
argumentative. His father locked him in the home for several days. This was distressing for the
client. He thought that his father no longer loves him. His arguments with his father increased
day by day and he felt himself at distant to his father.

Client’s mother was 52 years old. She is a beautician by profession. She has set up her beauty
salon in her home. There is no fixed time of her duty. She works there only the times when any
client came for services. She has always taken care of the needs of the client and his siblings. His
parents have love marriage and has congenial relationship. Her mother got very emotional when
she came to know about drugs and requested him to quit drugs many times.

Client is the firstborn child in the family. He has a sister who is 19 years old. She is the student
of graduation in a private university. He has a brother, who is 13 years old and is student of 7
class. The youngest sister is 11 years old and is in six class.
The client reported that, he is not close to his siblings. For past 5 years he visited home only once
or twice for the whole day and spent most of his time with friends and in activities that involved
drugs. He has no quality time with family.

History of Family Psychiatric/Medical Illness

There is no history of psychiatric illness in the family. No medical illness is reported expect his
father, who takes medicine of Diabetes. He has diabetes for last 5-6 years and takes medicines
for treatment.

Sexual History

Client reported a typical onset of Pubertal changes around age 12-13. He was adjusted to
those changes without any distress or difficulty. He was easily adjusted to the new bodily
developments.

Client reported sexual relationships with multiple girls. He maintained sexual relation for the
first time with a girl, who was in his neighborhood. He reported that he felt pleasure after his first
sexual encounter with his girlfriend. He had relationship with that girl for 2 years. They had a
close relationship. They often communicated through messages, video calls. They exchanged
romantic videos to each other. She knew about him taking drugs. She demanded him to quit
drugs. At the start of the relationship, the client committed to her that he will quit soon. When, he
did not quit after multiple commitments, she left him. The client was hurt at the break-up time.
He thought himself the reason of break up as he could not control on his urge to take drugs. He
felt helpless at that time. After 6 months, he got to know a girl through one of his addicted
friends. He did not commit to a couple relationship with that girl. He had sex for 3 times in a 3
months’ time period. They only met for 3-4 times. When he was in Dubai, there were some call
girls who took money to have sex. The client reported that he had that experience for 2 times.

The client reported enjoying the excitement and novelty of having multiple romantic
relationships, describing it as thrilling experience. He expressed a feeling of confidence to attract
and connect with various partners.

Informal Assessment
 i. Behavioral observation
ii. Clinical interview
iii. Subjective rating of the problems

Subjective Rating of the Problems

Subjective ratings of the problems of client,

Table No:03

Problems Ratings

Anxiety 8

Loss of interest in Activities 8

Worthlessness 8

Self-blaming 7

Formal Assessment

i. Mini Mental Status Examination (MMSE)

ii. Drug Abuse Screening Test (DAST)
iii. Rotter Incomplete Sentence Blank (RISB)
iv. House, Tree, Person (HTP)

Mini Mental Status Examination (MMSE)

 Mini Mental Status Examination (MMSE) was administered to evaluate the cognitive
functioning of the client including attention and memory. To rule out any underlying cognitive
impairment that can impact client’s ability to engage in treatment.

Quantitative Analysis of MMSE

Table No: 04

Total score Obtained score Category

30 29 No cognitive impairment

Qualitative Analysis of MMSE

The qualitative analysis of MMSE indicated that Client’s score is 29, which falls in no cognitive
impairment category indicates that he has no problem in cognition, memory and attention.

Drug Abuse Screening Test (DAST)

Drug abuse screening test (DAST) was administered to quantify client’s drug use
patterns, identify potential addiction and severity of drug use and related problems.

Quantitative Analysis of DAST

Table No: 05

Total score Obtained Category

28 20 (Over 12) substance abuse problem

Qualitative Analysis OF DAST

Qualitative analysis of DAST indicated that the client obtained the score 20, which is
above the cut off score 11. Over 12 is definitely substance abuse problem. Thus, client is with
substance abuse problem.
Rotter Incomplete Sentence Blank (RISB)

Rotter Incomplete sentence blank (RISB) was administered to assess client’s thoughts,
attitude and feelings towards himself, others and the environment. Client’s emotional struggles
and relationship patterns that may contribute to addiction were assessed.

Quantitative Analysis of RISB

Table No :06

Response Reponses Values Raw Score Cut off Adjusted/Maladjusted

categories
P3 0 0
Positive P2 1 1
P1 2 10
Neutral N 3 15
C1 4 12
Conflict C2 5 65
C3 6 42
Omission O 0
Total 145 135 Maladjusted

Qualitative Analysis of RISB

According to the qualitative analysis of RISB, client falls in category of maladjustment.

Client’s responses to RISB test are categories in four major categories. Participant gave 11
positive responses, 5 neutral responses 23 conflict responses and 0 omission. The qualitative
analysis of the responses given by the participant is done on the 4 dimensions; familial attitude,
social and sexual attitude, general attitude and character traits.

Familial Attitude

Client’s responses on item 11, (My mother is very good) and item 35, (My father is a
good person) indicates a positive relationship with his father and mother.

Social and Sexual Attitude

Item 40, (Most of the women are disloyal) indicated his conflicting attitude toward opposite
sex. On item 10, he responded (I don’t like people, wants to live alone), item 19, ( do not like
other people), Item 30, (I hate bad people). These responses indicated an inconsistent social
interaction.

General Attitude

Responses on Item 29, (Imprisonment is hurtful for me), Item 31(I hate this place), Item
33(The problem is that I can’t go away from this place) shows a general attitude of
discontentment, longing for escape and concerned about to get free.

Character Traits

On item 9, client’s response, (I get annoy when someone tease me) indicates emotional
sensitivity and an emotional need for respect. On item 8 (I am not best), item 18 (My nerves are
not strong) and item 32, (I am a very bad boy), these responses show feeling of worthlessness,
low self-esteem.

House Tree Person (HTP)

House Tree Person (HTP) was administered to explore client’s personality, emotional
functioning. Emotional conflicts were assessed.

Qualitative Interpretation of HTP

 The analysis of House-Tree-Person (HTP) indicated that client seems to have inadequate
self-image and low self-esteem. Client seems to have need for affection. Due to unsupportive
environment, client has feelings of inadequacy which leads to worthlessness and helplessness. To
overcome his anxieties, he uses defense mechanism of Rationalization. Feelings of isolation and
insecurity alternatively affected his interpersonal relationships. Client seems to have voyeuristic
and sexual conflicts. He deals with these tendencies through sexual fantasies which leads to poor
psychological health.

Case Formulation

Client was a 21 years old male. He was referred by the psychologist of Manzil e Nau with
presenting complaints of lack of interest in activities, worthlessness and worry accompanied with
the abuse of poly substances.

As evident from the clinical interview information, client’s privileged upbringing being the
eldest sibling in the family might be the predisposing factors of client’s addiction. As the
research suggests that individuals from affluent backgrounds may be more susceptible to drugs
addiction (Khan et al., 2018).

The facilitation of the drugs by the social circle (friends), was identified as his precipitating
factor. The ease of access to drugs due to family’s wealth and social circle pressure (as friends
taking drugs) identified as Maintaining factors. A study has revealed that individuals who had
friends who use drugs and facilitate the drugs to them, are more likely to develop drugs addiction
habit (Ford et al., 2013).

Protecting factors include family support, it has helped him to seek treatment and work towards
the recovery. Researches has consistently proved the crucial role of family support. A study has
resulted that Individuals who received family support and involvement in their treatment had
better outcome results (Mckay et al., 2010).

Pictorial Description of Case Formulation

Adult

M.S 21 years old, Male

 Presenting Complaints

Loss of interest, feelings of worthlessness, worry

Precipitating Factors
Presdisposing Factors Maintaining Factors Protective Factors
Access to drugs by social
Privilegded upbriniging Upper socio economic family support
circle

Tentative Diagnosis

F12.20 Cannabis Use Disorder, Severe, In Early Remission, In a controlled Environment

F11.20 Opioid Use Disorder, Severe, In Early Remission, In a controlled Environment

F15.20 Stimulant Use Disorder, Moderate, In Early Remission, In a controlled Environment.

Prognosis

The client prognosis is good as his supportive family and his motivation to recover may impact
his ability to achieve lasting recovery. His physical health is good and living environment is
drug- free. Availability of ongoing care may contribute to his recovery.

Limitations

 The rehabilitation environment was inadequate, constant noise and distractions affected
the clint’s concentration.
 Family counseling sessions could not be arranged to support client’s recovery.