Age 61 years
Number of Siblings 2 sisters
Birth order Second child
Marital Status Widower
Source of referral Social worker
Date of referral 2017
Reason for Referral
The client was referred by a social worker at Old Homes for complete psychological assessment and management
(According to Client )
The client reported that following symptoms were present
(All the complaints are present since five years)
(A resident of Old Home)
(All the complaints are present for two year)
History of Present Illness
The client was referred to the trainee psychologist as the client reported the problems of loneliness, depression, hopelessness. The client was facing all these problems from last five years after the death of his wife in a road accident and in that accident he became disabled and wasn’t be able to walk, he was in old home from May 2015.
Client reported that his problems started after the death of his wife. She died in a car road accident in January 2011 and in that accident he got injured and lost his leg and became disabled. His body was very injured in the accident after that he faced loneliness after the death of his wife. He lived with his only child in Lahore. but after his disability the behavior of his son was completely changed with him . His son and his family didn’t care about him they even did not care about his meal. As he was old and disabled as well he was not able to perform his daily activities so he was dependent on them and they misbehaved with him. His daughter in law often asked her husband that she was not able to tolerate him at home and leave he had to leave his father to any other place in front of him. The client’s both sisters were dead in past years so he had on another place to live. his son left him in old home and excused that he was not able to bear the expenses of his medicine and he had his own family and he had to look after them too so when he will have enough money he will take him to home, client reported that he was very sad because he was not willing to leave his own home . he felt loneliness and helplessness in the old home as he has no friend there and have no such activities which could engaged him busy.
Client belonged to a middle class family. His father died when she was 22 years old and mother died when she was 25 years old. His mother and father were relatives. His father did job in Pakistan Army and after some years of retirement he got ill. He died after lung cancer. His father was a religious and pious man he was very friendly in nature, supportive and kind. He always taught him the good manners. The client had satisfactory relationship with him. The client’s mother was house wife and an illiterate lady. His mother was reported to be friendly, soft and kind hearted. he also described that there were very difficult times in her family regarding family issues but her father and mother handle those issues very well and did not let their children suffer.
She had two sisters. According to him, he had very satisfactory relation with his sisters As reported by client there was no history of psychiatric illness in the family. But the problem of high blood pressure and sugar was inherited in his family
According to the client, he was born in home in Lahore on 9 September 1951. The client’s birth was normal and he was a full term baby. According to him, his mother did not face any problem during pregnancy or at the time of birth. No history of smoking or alcohol use was present. Overall, the client was a healthy baby.
The client completed his developmental milestones at proper age. He was breastfed for about one year. The client started crawling 10 months, standing at almost 1 and half year and running at 2 years of age. Client was able to talk fluently at the age of 2 years. Client sleep pattern were normal in childhood. The client had no neurotic traits like nail biting, excessive fears, temper tantrums, sleep walking, thumb sucking etc. There was no history of physiological illness, psychiatric disorder or major injury.
The client started his schooling at the age of six in the year 1956. He was an average student, who attended his school regularly and never had much interest regarding studies. He had many friends in school and his relationship with her class fellows and teachers was satisfactory. he had interested in school activities like extracurricular activities.
He completed her matriculation in the year 1969 at the age of 18 years. After that he got admission in college near their home in 1970. After that he get admission in the Govt university and completed his bachelor in English there. He was the first educated child of his family
The client got her religious education from her father and completed the recitation of Holy Quran under his supervision at the age of 8 years. After completed her studies, the client started his job in a Govt college as an English teacher in 1975 .
The client was friendly in nature and he enjoyed playing with his friends in his childhood. He had many friends and he liked to play games like cricket, guli danda with boys near his home. He was very naughty in his childhood and often annoyed his friends and family with tricks. He liked to watch movies in his childhood. The client didn’t have any forensic history. She never had taken any drug, or went to jail, her police record was clean and clear. Over all, the client social circle was not very large but currently many of his friends died so he reported that he really missed them and their golden time as he stated:
The client reached the age of puberty at the age of fifteen years. The client was not aware of sex before his marriage and he did not have any sexual experience before his marriage. He had not any sexual abuse experience in his life.
The client got married in the year 1980 outside the family. The client did not know his wife quite well, before the marriage because it was an arranged marriage.
The clients’ wife was illiterate . The client had one sister in law and three brother in laws. Client have a satisfactory relation with her sister in law and two brothers in laws while her one brother in law according to they often supported him a lot in many financial matters. The client took care of his mother in law when she was severely ill.
The client relation with his wife was very satisfactory in their marriage and they were blessed with a baby boy in 1982. He was very happy with his wife and son . They were lived in a joint family system Small disputes started on small reasons such as on cooking, washing, between his wife and her in laws after those disputes he left his father’s home and settled with his family in a new home near Canal.
The client spend a happy and satisfied life but now days after his wife’s death he wanted to go back to his house and want to spend the remaining days of his family with his grandchildren. According to client he did not want to live in an old house with strangers rather he want to live with his son and grandchildren but his son did not want to live with him. According to him:
The client was physically weak. As reported by client he has deficiency of blood in his body and he often felt tired but nobody is there for him for his care.
The client was living a happy life before retirement and disability with his wife and family. He had a very good relationship with his neighbors and he always took care of them and help them when they need, he performed his daily life activities in a proper way.
Informal Psychological Assessment
General Appearance and Behavioral Observation:
The client had a normal weight. His behavior was cooperating. He was looking a decent and sensible man by appearance. He looked friendly. He was physically weak he was dressed properly according to season. On appearance there as no sign of abnormal activities. He maintained eye contact during session.
Form of Speech
Form of speech was spontaneous and he responded in sentences. Speech was comprehensible and understandable. Volume of speech was low. He spoke softly throughout the conversations.
Content of Speech
The client’s content of speech was appropriate and it was somehow intellectual manner.
The client was reported that she was not feeling well, was sad and unhappy.
The client was looking depressed and anxious. He was worried and sad about his current conditions as he was in old home
Client’s content of thoughts was appropriate. His response was relevant to the question asked. client had a view that he was depressed and sad. He felt himself lonely most of the time.
The client had no problem in expressing his thoughts. He could express his feelings easily. Overall he maintained his stream of thought well.
The client visual perception was appropriate. He had no problem in copying the patterns of different drawing. He sometimes got confused due to poor attention but he easily recognized words and had no visual difficulties. Symptoms such as illusion, misinterpretation, depersonalization, passivity phenomena were not elected.
He was able to repeat what was said to him. He was able to understand oral instructions given to him and could hear the questions easily. He understand the conversation and learning delivered at normal rate. So it seemed that he did not have any visual or perceptual deficits as she did not have any visual or perceptual deficits as she was appropriately answering to all the questions correctly.
The client’s receptive speech was relevant and there was no difficulty for him in telling the meaning of the words like house, Window and road. He pointed out her right/left body parts. He received the instructions easily. He also captured the sounds of different words easily.
The client’s expressive ability was understandable. At the starting of the assessment he was hesitate it seemed that she had difficulty in expressing himself in speech. He was not quite expressive. He not only gave answers to my all questions.
Gross motor skills
The client showed physical problem. He could not walk like normal people after his accident.
Fine motor skills
His writing was legible. He could repeat all the sentences. He could tell his past and present happening almost all.
General Fund of Knowledge
The client did have adequate general knowledge when he asked to:
Comprehension and Vocabulary
He had appropriate comprehension. He properly and reasonably answered all the questions and coveys whatever I asked him, he seemed to be unwilling to engage in the tasks related to vocabulary.
The client had adequate abstract reasoning.
Short term memory
Short term memory was integral.
Long term memory
The client long term memory was intact.
The client seemed to be a well oriented towards time.
He was very oriented about person.
He also seemed to be well oriented towards place.
She also seemed to have insight of his problem. He was aware of being ill.
Formal Psychological Assessment
In formal psychological testing different standardized tests are administered to the client to depict the clear picture of the client’s problems.
The formal psychological assessment was based on three levels.
- Intellectual Assessment
Otis Quick Scoring Mental Ability Test (Otis)
Rotter’s Incomplete Sentences Blank (Rotter)
- The) Beck Hopelessness scale (Beck)
- The Beck Depression Inventory (Beck)
Otis Quick Scoring Mental Ability Test
Otis Quick Scoring Mental Ability Test was administered to assess the mental ability, thinking power or the degree of intellectual maturity of the client.
Table showing Responses Otis Quick Scoring
The client’s raw score is 30 and after adding a constant of 72 for the age range of 50 years the client’s standard score on Otis Quick Scoring Mental Ability Test becomes 103 which is within average range of (80-115). So the score of client indicates that he has average intellectual capacity.
Rotter’s Incomplete Sentences Blank (RISB)
RISB was administered to the client for assessment of her personality and index of maladjustment. Following result was obtained:
Table Showing Responses of RISB
Table Showing the Percentage of the Responses of RISB
Table Showing Cut-off Point of RISB
The client’s total score on RISB is 129. The cut-off score 135. This reflects that client’s score is below than the cut-off point and it shows that her personality is quite adjusted although he has pessimistic approach towards life and future.
- Family attitude:
The client seemed to had pessimistic attitude towards his son and his wife.
- Social and sexual attitudes:
The client’s responses to various items suggested that he had a positive social attitude. He did not wants to remain alone.
- General attitude:
The client’s attitude towards his childhood seemed to be positive as indicated by following responses:
- Character traits:
The clients had a negative approach towards life. However he had some positive views about herself.
Trait – Specific Assessment
The Beck Depression Inventory (BDI)
Beck Depression Inventory was administered to the client in order to assess the level of depression and following results were obtained:
Table Showing Scores of (BDI)
The client’s raw score on BDI is 20 which fall within the category of mild depression (14 -19). The results of test revealed that the client is suffering from mild depression.
Beck Hopelessness Scale (BHS)
This scale assesses three aspects of hopelessness: feelings about the future, loss of motivation and expectations. It is useful for predicting eventual suicide. It is Self-administered questionnaire or may be administered via interview. It include three factors: affective, motivational, and cognitive aspects of hopelessness
Table Showing Scores of (BHS)
Scores Hopelessness level
14 Moderate hopelessness
Client scored 14 on Beck hopelessness scale that showed that client is moderately hopeless. This is consistent with clients’ history as he had uncertainty and vagueness about her future.
Perceived loneliness scale ( PLS )
It consists of 36 items. Each item is answered on five point likert scale. Eight items are reversely scored. The score on PLS shows a person’s perceived loneliness (kumar,1997)
|Total time||Scored obtained||Range||Loneliness scale|
The client obtained 121 scored on PLS and it showed that client had moderate level of loneliness.
Identification of problem
The client was living in the old home from last two years as his family was not willing to live with him. After his disability he had faced many problems. The client was sad, helpless and worried about his condition as he is unable to do his daily routine task on his own and he felt himself a burden on his family. He felt loneliness because he missed his wife, son and grandchildren. He wants to live a respectful life with his family again.
The client was 61 years old and living in an old home from last two years because of some personal problems. The client was feeling helpless and lonely in old home. The psychological assessment was carried out on both formal and informal level. The informal assessment. The result of assessment indicated that client had moderate helplessness, mild depression and moderate loneliness.
Aging can o be defined as a progressive functional decline, or a gradual deterioration of physiological function with age, including a decrease in fecundity or the intrinsic, inevitable, and irreversible age-related process of loss of viability and increase in vulnerability. Clearly, human aging is associated with a wide range of physiological changes that not only make us more susceptible to death but limit our normal functions and render us more susceptible to a number of diseases.
Some natural body changes associated with aging may increase a person’s risk of experiencing depression. Recent studies suggest that lower concentrations of folate in the blood and nervous system may contribute to depression, mental impairment and dementia. Regardless of its cause, depression can have alarming physical effects on older people. The mortality rate for elderly men and women suffering from both depression and feelings of loneliness is higher than for those who are report satisfaction with their lives. Treatment programs for depressed elderly patients suffering from cardiovascular disease and other major illnesses usually take longer than normal, and are less successful (Mohan, 2013).
It is founded that experience of stressful life events is associated with an increased risk for a person to become depressed This research is relevant to the case of my client as she also had faced many stressful life event’s for example financial crisis, mother death and even death of her father, that had changed her life and development of her depression (Paykael & Dowlatshahi ,2000). As the client faced the incident of death of his wife and a horrible accident, this effects him a lot and often made him sad. He consider this his fate so it seems he is suffering from mild depression not severe which could be manageable with proper care .
Lonely seniors are more likely to decline and die faster. The study also found that people 60-years-old and older who reported feeling lonely saw a 45% increase in their risk for death. Isolated elders also had a 59 % greater risk of mental and physical decline than their more social counterparts (Paykael &Dowlatshahi ,2000). As the client feeling lonely and missed his beloved one them it could be related that he is suffering from moderate loneliness.
In this current case client scored show hopelessness in him This hopelessness is related to his future being a disable person it was the reason he is now outside of his family. The cause of helplessness can vary from one person to another. Usually when they are neglected and there needs are not satisfied most of the time, they tend to develop this. As in the case of client his children did not took proper care of him and did not care about his needs, he was treated as an expensive burden that’s why he developed helplessness.
Management plan is design to help the client to resolve his problems and to return his back to the community sound and healthy. Several therapies and introversion are designed for this purpose.
The main purpose of psycho education is to educate the client about the condition and its management to help the client to deal with the problem by himself. The client need to be educated about his problem and factors which 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 physician to make him better .
As its name suggests, behavioral therapy is focused on human behavior and looks to eradicate unwanted or maladaptive behavior. Typically this type of therapy is used for those with behavioral problems or mental health conditions that involve unwanted behavior. In the recent case client behavior of sitting alone will be replaced by talking with fellows, watching TV or reading different magazine of her interests
Cognitive Behavioral Therapy
It is an active, directive, usually more focused on the present, more time-limited, and more problem-solving oriented. In addition, patients learn specific skills that they can use for the rest of their lives. In this case client is having cognitive distortion i.e. Catastrophizing (fortune–telling), in this an individual predict the future negatively without considering other, more likely outcomes. Client is using statement like she thinks that her future is not protected. She is fortune telling on the basis of her current situation. Her problem needs to be fixed by using different behavioural therapies or treatments (Leahy, 2003).
In Gestalt therapy the client is encouraged to bring out hidden feelings. Much use is made of something called the ‘open chair’ technique. This is when the client sits opposite an empty chair and then mentally places into that chair someone significant, who has caused them pain or trouble. In this case this technique will be helpful in venting clients’ unexpressed emotions for her husband and family members. This technique will provide relief to the client also will be helpful for therapist in understanding underlying problems of the client.
Teaching changing and coping skills
Client can be taught to be aware of his feelings and thoughts when they occur, the client could help himself when he feel depressed by fallowing strategies increased his activity level, redirect thoughts to pleasant experiences, using productive daydreaming. All the strategies have one common fact that they empower the client with it and put him in control to actualize change.
- The client must have good and healthy home environment. Her family member should support him .
- There is a need to work on the self-esteem and the self-image of the client as due to disability he considered himself useless and helpless.
- The environment of Old Home was not suitable for psychological assessments because there were continuous distractions.
- There were limited number of sessions because of the unavailability for more sessions
- During the testing sessions there were a lot of outside noise and client was constantly distracted by the outside noise so the result of psychological testing cannot be considered as significant.