Counseling Case Report

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.

Speech and Thought

• Content

His content of speech was adequate and understandable with appropriate answering of all questions. Progression of speech was quite slow.He was logical and meaningful. His speaking was in an organized way. He was frequently speak Urdu. 

• Form

He spoke in average and serious tone, his volume was quite low and his speech was comprehensive.

• Thought

Client’s thought process was quite inadequate. As following questions were asked to the client.

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.

He could easily identified his right left parts very well.

Mah – Tuh – Suh-  Puh

He was able to recognize information well.

• 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.

Sp (as a spot), PL (as a play), Th (as a thing)

Mood and Affect

Objective The client seemed to be with fine mood. His mood got low at explanation of his accident.

Subjective He reported that he is in fine mood was comfortable in sitting.

Affect Client’s affect was appropriate to the situation.

Range His affect was restricted did not show high emotions.

Intensity Client’s intensity was flat.

Quality He was sad and after sometime he became anxious.

Perception

• Visual Perception

                        The client’s visual perception seemed to be adequate.  He can easily read and understand the things. He can easily read all the formal tests provided him. 

• Auditory Perception

He was having an excellent auditory perception. He was able to understand the instructions given to him and could hear the questions easily. He could easily differentiate between the sounds of people around. He could understand the conversation indicating well auditory perception.

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.

1: What is capital of Pakistan?

Ans: Islamabad

2: Who is the poet of Pakistan?

Ans: Allama Iqbal

3: When do we celebrate Independence Day?

Ans: 14^th august

He was easily answered all these questions.

• 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.

But he did not answered the difficult. Like  

• Vocabulary

                        The client’s vocabulary of English was quite below average as he was not able to spell communication, celebrity, generation, but the vocabulary of Urdu was better as compare to English. As he tell the correct meaning of Urdu word. 

• Attention and Concentration

             The Clients attention and concentration seemed to be above average. He remained attentive during the sessions and answered to questions attentively and also showed high interest in attempting psychological tests. 

Memory

• Short Term Memory

                        The client’s short term memory was good. He was able to recall things properly. He could memorize the name of his institute and his teacher’s name. Which dress he had worn yesterday.

• Long Term Memory

                        The client’s long term memory was also above average. He can recall his address, his date of birth. He was able to memorize his early school days. He also memorized the incidents concerning to his past life.

Orientation

The orientation of time place person was accurate. He could report the time exactly. As some questions were asked what is day today? What is date today? How would you describes this situation? He knew the persons around well, also was well aware of the place he was living in. He easily answered all the questions.

Insight and Judgment

The client had well developed insight of his problem. He knew his responsibilities, he knew that studies is essential part of life. So, he worried about his studies. As some questions were asked by him

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

___________________________________________________________________________

Formal Psychological Assessment

As the client was very cooperative and motivated to take part in the session. After taking his consent to complete the tests relevant to his problem they were filled by him as the tests were too long so client was able to complete them in two settings. Formal assessment was done with the help of standardized tests and inventories which are described as follows:

1. Child Depression Inventory (CDI)
2. The Self Image Profiles for Children (SIP-C) and Adolescents (SIP-A)
3. The Adolescent Anger Rating Scale (AARS)

Child Depression Inventory (CDI)

The Child Depression Inventory (CDI) is a symptom-oriented instrument for assessing depression in children between the ages of seven and 17 years. The basic CDI consists of 27 items, but a 10-item short form is also available for use as a screener. The CDI was first published by Maria Kovacs in 1992. It was developed because depression in young children is often difficult to diagnose, and also because depression was regarded as an adult disorder until the 1970 (kuvacs,1992).

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 Score	T score	Cut off	Remark
05	56	56-60	Slightly above average Depression

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

Responses	Items no.	Scores	Cut off	Description
SI+VE	Sum of items 1-12	33	35	low positive self-image
SI-VE	Sum of items 14-25	52	52	High Negative self-image
SE	sum of discrepancy scores	87	76	Cause of concern

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.

The Adolescent Anger Rating Scale (AARS)

The adolescent anger rating scale (APS) was designed to help clinician’s asses several aspect of anger, total anger, specific type of anger (i.e., instrumental anger and reactive anger) and anger control in adolescent ages 11 to 19. The AARP is appropriate for use in clinical settings as both a screening measure for social maladjustment behaviors and as a measure of treatment affects. In school setting, the AAPR provides an efficient and economic screening, instrument for adolescents who demonstrate anger pattern that are potentially harmful to themselves or others (Deanna,2000)

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

Scale	Raw Score	T score	% ile	Interpretation
Total Anger	90	55	73	Average Level of anger
IA	33	53	73	Average Level of anger
RA	20	57	78	Average Level of anger
AC	28	46	40	Average Level 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.

Summary of Psychological Assessment

The client’s scores on child depression inventory showed that he had slightly above average depression. According to the scores on self image profile for children showed that he had low positive self image, high negative self image and low self esteem. The scores on adolescent anger scale 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 level 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
• Cognitive Behavior Therapy
• Rational Emotive 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.

Sleep Hygiene Principle

General

Go to sleep at about the same time each night, and awaken at the same time each morning.  Wide fluctuations between workdays and days off can further impair your sleep. Try not to nap. If you do, restrict this to about an hour per day, and do it relatively early (before about 4 in the afternoon). If you are not sleepy, either don’t go to bed or arise from bed.  Do quiet, relaxing activities until you feel sleep, then return to bed. Avoid doing stimulating, frustrating, or anxiety provoking activities in the bed or in the bedroom (watching television, studying, balancing the checkbook, etc.).  Try to reserve the bedroom and especially the bed, for sleep.

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).

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is the most widely-used therapy for anxiety disorders. Cognitive behavioral therapy addresses negative patterns and distortions in the way we look at the world and ourselves. CBT is one of the most effective treatments for depression, and has been found to be useful for a wide range of people, including children, adolescents, adults and older people.

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.

Rational Emotive Behavior Therapy

Rational Emotive Behavior Therapy (REBT) is both a psycho therapeutic system of theory and practices and a school of thought established by Albert Ellis.

Disputing

This is an active approach for helping clients evaluate the helpfulness and efficacy of elements of their belief systems. Once the client is familiar with the ABCs of REBT, disputing will allow her to identify debate and ultimately replace her thinking and beliefs which are generally getting her into trouble and are the cause of her compulsive acts or maladaptive behavior patterns (Ellis & Maclaren, 1998).

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).

Rational Coping Statements

Rational coping statements are self statements which usually are implemented after disputing has been accomplished, but they can also be used when the client is in the process of exploring her beliefs. These factual, encouraging phrases are consistent with social reality and client can be encouraged to repeat them consistently to reinforce the ideas for her. The may be encouraging statements such as “I can accomplish this task” or “I don’t have to get upset in these situations” (Dryden, 1994; Ellis, 1957, 1988; Yankura & Dryden, 1990 as cited in Ellis & Maclaren, 1998).

Biblotherapy / Psycho educational Assignment

In this technique therapist supplement the therapy content with bibliographic / psycho educational assignment to further reinforce the work the client doing in session. Assigning helpful audio cassette, videos, pamphlets, books, lectures, workshops and topic specific group can all contribute to client understanding of his problem and progress in changing inappropriate and unhelpful reactions. As in the client case material was provided to motivate him that many people also have amputee of different limbs but they cope with the situation and are working in a good way (Ellis &Maclaren, 1998).

Mindfulness based cognitive therapy (MBCT)

MBCT is generally delivered in groups and involves learning a type of meditation called ‘mindfulness meditation’. This meditation teaches people to focus on the very present moment, just noticing whatever they are experiencing, be it pleasant or unpleasant, without trying to change it. At first, this approach is used to focus on physical sensations (like breathing), but later it is used to focus on feelings and thoughts. MBCT helps client to stop their mind wandering off into thoughts about the future or the past, or trying to avoid unpleasant thoughts and feelings.

Self Esteem Building

Building your self-esteem and creating a positive self-awareness comes from taking an inventory of your own strengths and abilities as a human being. This “inner peace” does not mean that you are unaware of your weaknesses; it merely means that you accept who you are and genuinely like the person you have become. Low self-esteem is often linked to depression or anxiety. If your emotions feel overpowering or out of control, one way to build self-esteem around this issue is to learn to manage your mood and gain control over your feelings. Some people are able to do this with the help of friends and family. Others need to work with a mental health professional to manage the problems that may lie beneath the surface of low self-esteem (Ponton, 2013).

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.

Traffic Signal Technique

When teaching anger management to client, a traffic light is effective at encouraging the identification of angry emotions. The color red represents stopping, and is useful when client begin to lose control of their emotions. Yellow offers client an opportunity to think and find an appropriate solution to their problem, and green lets them know they can move forward in a responsible way. Just as a driver who runs a traffic light risks getting a ticket or causing an accident, a client risks punishment, personal injury, or inflicting injury on someone else by running an anger traffic light. The three colors on a traffic light can represent the three stages of emotion a client passes through when becoming angry. Green represents calm and relaxation, or the state before anger begins to develop. Yellow symbolizes the build-up of angry emotion that typically occurs when the client first encounters a stressor. Red represents the client’s reaction to the angry emotions.

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;

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