Case Presentation

Presented by

Faisal khan
Enrollnment no. 03-275241-008
MSCP-3rd A
Identifying Information
• Name: J
• Father’s Name: M.A
• Gender: Male
• Date of Birth: 31/12/1982
• Age: 43 years
Referral Source

• The client was referred to the intern clinical psychologist by the

senior supervisor at Umeed Clinic for the assessment and
management of his complaints.
‫‪Presenting Complaints‬‬
‫گھبراہٹ سی ہوتی ہیں‬
‫غّصہ آتا ہیں‬
‫نیند میں دشواری ہیں‬
‫توجہ دینے میں ُمشِکل پیش آتی ہیں‬
‫سر میں درد رہتا ہیں‬
‫بے چینی سی محسوس ہوتی ہیں‬
 Clinical Interview
• The client was presented with complaints of withdrawal symptoms
due to addiction to multiple drugs, depressed mood, headache,
difficulty concentrating, restlessness, sleep difficulty and
shakiness during the withdrawal phase, emotional disturbance,
negative thoughts, aggression, low self-esteem problems,
nervousness and anxiety about the relapse
• The client had been experiencing significant difficulties due to
long-term polysubstance abuse, including heroin, ice, charas and
alcohol, which the client had been using for the past 16 years, but
last time before getting admitted, the client used cannabis.
Currently, the client is undergoing treatment at Umeed Clinic
Rehabilitation Center.
Clinical Interview
• The client reported that he started using drugs with his friends 16
years ago, as a result, his health condition got worse loss of job
• The client used to take drugs daily, 3 to 4 times or whenever
available..
• The client's current treatment and therapy were taking place at
the Umeed Clinic Rehabilitation Centre in Lahore.
• The client was a 43-year-old male. He was 6th among his
siblings, and his birth order is first. The client has two elder
brothers and three married sisters. The client's father passed
away 25 years ago. His mother is a 65-year-old housewife and
lives with his elder brother.
 Clinical Interview
• The client has an arranged marriage, and his wife is a 40-year-
old housewife. He has three children: two sons and one
daughter. The client was a very responsible person before his
addiction to multiple drugs.
• he used to work in a private organization, but he left that job
after he started to take drugs with his friends, he used to spend
time with family and children, and the client had a good sexual
relationship with his wife but after his addiction he used to
become aggressive, not giving time to family, fights, and issues
with wife and not having good sexual relation with his wife.
• The client studied Matric. He had good relations with peers and
teachers
• The client’s orientation of time, place and person was intact.
Test Administration

• Bender Gestalt TEST-KOPPITZ-2 (BGT-KOPPITZ-2)

• Test of Non-Verbal Intelligence (TONI)

• Drug Abuse Screening Test (DAST-10)

• University of Rhode Island Change Assessment (URICA)

• Human Figure Draw(DAP)
• Rotter Incomplete Sentence Blank (RISB)
Behavioral Observation
• The client was 43 years old. The session was taken in his bed. He
was adequately dressed and looked neat and clean. The client
dressed according to the weather. At the time of the interview, he
was cooperative, but he was too sad while talking about his
concerns. When asked about his feelings and life, he was low and
feeling bad about taking drugs. . During the assessment, the client
faced difficulty in completing various tools, including the Bender
Gestalt Test -KOPPITZ-2 (BGT-KOPPITZ-2), Test of Non-Verbal
Intelligence(TONI), Drug Abuse Screening Test (DAST-10),
University of Rhode Island Change Assessment Scale (URICA),
Human Figure Draw(DAP) and Rotter Incomplete Sentence
Blank(RISB)
Bender Gestalt Test-KOPPITZ-2 (BGT-
KOPPITZ-2)
Total Raw Visual Motor Percentile Descriptive
Score Index Rank Rating

26 90-109 34 Average
Bender Gestalt Test-KOPPITZ-2 (BGT-KOPPITZ-2)
• The client took 25 minutes to complete the Bender Gestalt test;
his total raw score was 26, with a visual motor index of 90-109.
The client's score falls in the category of Average rating. The
minor mistakes may reflect common challenges with slight motor
coordination difficulties, but they do not indicate any significant
deficits in the individual’s ability to process visual information or
execute motor responses.
• The client’s drawing also included emotional indicators of
Progressive increase in size, indicating low frustration tolerance
and large size indicating acting out behavior, and Small size
indicating anxiety
• The second attempt is associated with impulsivity and anxiety.
Test of Non-Verbal Intelligence (TONI)

Raw Index Percentile Descriptive

Score Score Rank Term
21 85 16 Average
Test of Non-Verbal Intelligence (TONI)
• The client’s raw score falls in the category of Below Average,
which means the below-average non-verbal intelligence reflects
that the individual has difficulty with complex patterns and logic-
based tasks and often requires support that demands higher-
order thinking or problem-solving. Nonverbal intelligence
includes abstract reasoning, Shapes and patterns, sequence
completion, Multiple-choice puzzles, and problem-solving.
Drug Abuse Screening Test (DAST-10)

Total Score Degree of Problems Related to Drug Suggested Action

Abuse

08 Substantial Level Intensive Assessment

Drug Abuse Screening Test (DAST-10)
• The client scored 8 on the drug abuse screening test (DAST-
10), inidicating a substantial level of severity and intensive
assessment.
• He had used more than one drug. He had failed in quitting the
substance use in the past. He had obtained drugs through
illegal ways.
• The drug use had severely impacted his familial (siblings,
spouse) relationships.
• He felt bad and guilty about his substance use.
University of Rhode Island Change Assessment (URICA)

States Average Readiness Score

Classification
Precontemplation 2.33

Contemplation 4

Action 3.33

Maintenance 3.33

CAM Score 10.66

Readiness Score 8.5 Contemplation

University of Rhode Island Change Assessment
(URICA)
• A score of 8.5 means the individual is in the Contemplation stage
of change. This means that the person acknowledges the client
has a problem and is contemplating making changes, but they
are not fully committed to action yet
• At this stage, the individual acknowledges that their current
behavior is problematic, but the client is still unsure about how to
proceed or whether change is necessary right now.
.

Human Figure Draw(DAP)

• The drawing indicates a strong internal focus on sensual needs,
like focus on body and comfort, self-awareness (shaded hair)
• Combined with cognitive distortions and psychotic features
(disproportionate head, disproportionate ears, disproportionate
feet). Emotional withdrawal and avoidance of reality - dimly
drawn facial features and closed eyes.
• Suppressed emotional expression (single-line nose and mouth)
• Alongside a strong need for control (emphasized neck)is also
present.
Human Figure Draw(DAP)

• Although some openness exists (open arms), the figure’s

dependency (fewer than five fingers), insecurity (single-line
legs), and masculine assertiveness (angular trunk)
• The Human Figure Drawing (HFD) indicate signs of emotional
instability, cognitive distortions, withdrawal tendencies,
emotional suppression, dependency, and perceptual
disturbances. Multiple indicators suggest underlying psychotic
features and difficulties in emotional regulation.
Rotter Incomplete Sentence Blank (RISB)
• The overall score is 137, which indicates a maladjusted score.
• High scores in C2 (60) and C1 (32)indicate stress and
overthinking.
• In the family dynamic client has deep joy and fulfilment in
spending time with children, reflecting a strong emotional
connection to the family
• In Personal, the client looks back on school and childhood with
warmth, remembering them as happy times
• Interpersonal the client. These responses indicate frustration and
disappointment with people, likely due to negative experiences.
The statement about hatred and unpaid money indicates feelings
of disloyalty and broken trust.
Tentative Diagnosis
• (F12.93) Cannabis Withdrawal
Prognosis
• The client’s prognosis is unfavorable due to several factors, including
long-term substance use (16 years), psychological distress (low self-
esteem, aggression, anxiety), and social isolation.
Conclusion

• The client, a 43-year-old male with a history of polysubstance

abuse for 16 years, indicates significant psychological,
emotional, and behavioral impairments. The client exhibits
withdrawal symptoms, emotional distress, anxiety about
relapse, and difficulties in social and familial relationships.
• Psychological assessments indicate below-average non-verbal
intelligence, substantial drug-related problems, maladaptive
coping mechanisms, and emotional instability. The client is in
the Contemplation stage of change, recognizing the need for
intervention but not yet fully committed to action.
Protocols