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Case 05
Substance Use Disorder
(F19.259)
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Summary
Client F.Q was 26 years old man. He was referred to me by the in charge of rehabilitation center.
He was neat, clean and well dressed. He was addicted to substance use disorder from 6 7 years.
He started smoking at the age of 19. Now he has been drinking ice for the past 5 or 6 months.
The reason for this behavior is his breakup. He was cooperative. He maintains good relationship
with members. Client also reported a present guilt feeling about all the bad things he had done.
Client was ready to move forward positivity after treatment ends.
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Identifying data:
Name: F.Q
Age: 26 years
Gender: Male
No.of Siblings: 04
Birth Order: 3rd
Father: Alive
Mother: Alive
Informant: Client himself
Source of referral
His family brought him to the rehabilitation center
Reason of referral
Client was referred by the in charge of rehabilitation center to me for taking a detailed case
history on substance use disorder. He was addicted to ice, charas,smoking,afeem (opium) and
alcohol with psychotic illness depression.
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Presenting Complaints
Duration Complaints
دو تین ماہ میں میرا سات کلو وزن کم ہوا
دو تین ماہ نیند نہیں آتی تھ ی
چھ سات ماہ غصہ آتا تھ ا
تین چا ر ماہ س ر درد رہتا تھا
پانچ ماہ سے بھوک محسوس نہیں ہوتی تھی
Observational Assessment
Client was 26 years old boy. He entered in session hall with confidence. The client’s
appearance was well dressed neat and clean. He was maintaining good eye contact.
History of present problem
Client reported that his condition got worse from last one year because of his addiction to
drugs.
Personal History
As reported by client, my father and brother used to drink, so I also started drinking. I
was influenced by them. He started drinking at the age of 16, 17. He has been using alcohol
along with smoking hashish and opium for about 6 to 7 years. After that, he went through a
breakup, and due to depression, he started using meth (ice) for the last 5 to 6 months. The
amount of ice increased day by day.
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Family History
He was born as 3rd child in family. His father works as a butcher. He is unmarried. Client
relationship with family is good.
Educational History
He is uneducated. No interest in study.
Previous and present physical illness:
There was no previous and present physical illness
Psychological Assessment
Formal and informal assessment was done with the client in order to access and to decide
a counseling plan for the client’s problem.
Formal Assessment
Psychological test
Beck Depression Inventory (BDI)
Score Degree of the problem related to drug’s
0_9 Minimal Depression
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10-18 Mild Depression
19_29 Moderate Depression
30_63 Severe Depression
Score: 31
Etiology:
The etiology of patient’s condition are psychosocial and psychoanalytical factors
Assessment
Subjective Rating
BDI
Counseling Session
Session 1
Aim: Rapport building and identifying problem
The client F.Q came in. I greeted him and asked him to please come in and take his seat.
The client’s appearance; the client was well-dressed, neat and clean. He was cooperative. I
decided to make sure that the client is comfortable and told him he can make himself at home
here and whatever he would tell me will be confidential. I am an intern working here and he can
feel free to convey whatever he wants. He hesitated for a second then he said he is addicted to a
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drug known as ice, chars, afeem(opium), smoking and alcohol. It was an introductory session in
which the general problems of client were asked and the objective of communication was
discussed with the client.
Today’s session was able to achieve the purpose with which it started.
Session 2
Aim: Taking information about premorbid personality
Today, he seemed much more comfortable. I asked him to tell me more about himself,
how his life was before his addiction, his social interest, social relationship, and any past present
physical problem. He maintains good relationship with members. He was physically fit before
addiction. , In this session client’s pervious & present illness were also discussed. There is no
any previous and present physical illness. He has a psychiatric illness that is depression from last
5 6 months.
In this session Mental Status Examination was also done. He was well mannered person.
Maintain distance with me. He was maintaining good eye contact. In this session he told me
about his suicidal thoughts and has tried to kill himself as he was suffered from major depressive
disorder. After using ice, he neither felt sleep nor hungry.
Today’s session was able to achieve the purpose with which it started.
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Session 3
Aim: Administrating BDI (Beck Depression Inventory) test
I told the client that I would ask some questions and that they should answer them to assess the
level of his depression. Client’s score on BDI is 31 that’s fall in severe depression. The client
responded very cooperatively, and the test was completed in this way
Session 4
Aim: Checking his memory, attention and concentration
Today’s in this session client’s orientation was good as he respond accurately when asked
about the place, year, date, month. His rate of speed was normal. Client attention and
concentration was not so good. He only knew the days of the week. He didn't know the names of
the months. He also didn't know the names of the days in the correct order. His memory intellect
and vocabulary were not good. He was not able to recall the event from in past easily.
Today’s session was able to achieve the purpose with which it started
Session 5
Aim: Goodbye to client.
Today was my last session with the client. Client was ready to move forward positivity
after treatments ends. After the session ended, I said goodbye and wished him a speedy recovery.
