Psychological Assessment And Management for Adjustment And Emotional Problem
Name M. R
Age 21 Years
Number of Siblings 2
Birth order Elder child
Marital Status Unmarried
Education BS English
Father’s name A.R
Father’s Occupation Govt. Employer
Mother’s name S.R
Mother’s Occupation Housewife
Source of referral Parents
Date of referral 2017
Reasons for Referral:
The client was referred by parents for complete psychological assessment and management for adjustment and emotional problems.
(All these complaints are present for three years)
(All these complaints are present for three years)
History of Present illness:
The client reported that the problems started from three years back when she shifted with her father in city at the age of 18 years in 2014 after the death of her mother. She further reported that in 2001 When she was six years old her father divorced her mother and get married to her office colleague and shifted to city left her mother with her grandparents in another city. At the age of 18 years old after the death of her mother he came back and took her with him. They shifted to city in 2014. She was not adjusted within family and new college in city. She missed her mother. She was not happy in her fathers’ home because she was not attached to her father and her step mother. Her step mother’ behavior was not very good with her. She often asked her to leave her place and shifted somewhere else. She isolated herself from others at home and stared to remain quiet and sad anymore. Her father reported that she was not well adjusted with them, she often fought with them and others members of family. She often misbehaved. She did not talked to anyone in proper way and tried to avoid everyone and different situations, she did not have any friend as well. She did not go outside and we admitted her to university in 2014 but her interaction and academics was poor. She did not seemed interested in studies and often skipped classes. Client reported that she became friend with a girl who was drug addict and she also start taking drugs. Her behavior became more rude towards her family . According to the client after being addicted by drugs her family’s behavior became more ruder and her step mother often taunt her and asked her to leave her home. As she had poor family bonding and less social skills her self-image damaged day by day and she became frustrated and isolated.
Client belonged to an upper middle class family. Her parents had arranged marriage and were cousins. According to the client her mother was a housewife and was an educated woman.
The client’s father was a govt. employed and had a good job and he is a well-educated man. According to client, her father was a strict person. May be because of his strict nature she was not very close to her but she know that he loved her and he loved his father too but not very attached to him. According to the client he was a man of rules. Most of the time he remained busy in his jobs affairs so he spent less time with his family and children so comparatively he was less communicative with children and specially with her.
The client was less close to her father because her father shows very less affection to her and was strict towards his children. Although he was always being financially supportive towards the family.
His parents have not very cordial relationship with each other’s. They separated soon but still They did best to look after their children financially. They have no good mutual understanding between them that’s why they separated soon.
The client had a normal relationship with her step brother, he is younger than her she loved him so much but at the same time as like others she is not attached with her too but still she loved him . .
As reported by the client there was no previous records of any psychiatric illness in family.
The client’s birth was normal and she was a full term baby. She was approximately 6 and a half pounds at the time of birth. According to her, her mother did not face any problem during pregnancy or at the time of birth. There were no prenatal or postnatal complications reported. Overall, the client was a healthy baby.
The client completed her developmental milestones at proper age. She was breastfed for about one year. The client started crawling ten months, standing at almost one and half year and running at two years of age. Client was able to talk at the age of two years. Client sleep pattern were normal in childhood. The client had no behavioral problems like nail biting, excessive fears, temper tantrums, sleep walking, thumb sucking etc. There was no history of physiological illness, psychiatric disorder or major injury. According to the client she did not have any medical problem or any specific illness But due to the skipping of regular meals she feel so much weakness and she could not sleep well at night.
The client had good relationship with her grandmother and her mother she was very happy with her at her home. In school she did not have many friends to whom she was quite close. She had poor socialization. She hand few friends and with them she was closed. In school she was a good student ,Although she was shy but she scored good marks But after coming with parents she was not very social in college , she had no friend. She lacks interest in studies. Due to interaction problem she could not participate in the class. She had only one friend in the class According to client she used to talk to her but she had not very warm relationship with her.
She did not participate in extracurricular activities in college rather she liked to stay at home alone. She reported that she spend her leisure time watching television. She was not very social and only felt comfortable with few people in her circle. People irritates her, she did not want to be friend with anyone anymore.
Informal Psychological Assessment
General Appearance and Behavioral Observation:
The client looked weak. Apparently she was heighted but her weight was not age appropriate. She seemed to be under weight. Her dressed properly according to session. The client walked with a normal manner and she sat on the chair with a normal posture. In the beginning, the client was very reluctant in answering questions but later when the rapport was built and she understood the nature of history taking, the client started talking comfortably about everything. Initially it was difficult to establish rapport with the client because she was unable to maintain a proper eye contact. She was moving her legs and fingers were an indicative hesitate at that time. Her mood remained normal during whole session.
Form of Speech
The client’s speech rate was slow and volume was low and her speech quality was hesitant and emotional. She was not very talkative but she was friendly but her speech was comprehend able and understandable. She spoke logical and meaningful sentences.
Content of Speech
Her content of speech seemed regular she answered almost all the questions appropriately. Although she was avoiding questions about her relationship but no shifting of idea was noticed. Her speech was well organized.
The client reported that she was in sad mood.
The client seemed to be hesitating, confused and sad. She seemed to be depressed, agitated and worried. .
The client seemed as having depressive and sad thinking but all answers given by her were full in content and context.. She was giving answers relevant to the questions. It seemed that she had organized thoughts process. There was no suicidal ideation and also have no previous history of violence.
The client had minor difficulty in explaining her thoughts and in finding appropriate words to explain them. The client did not seem to have any formal thought disorder such as pressure of thoughts, poverty of thought or flight of Ideas. There was no disturbance of speech.
She was able to understand and represent whatever she was asked. Moreover she easily recognized the relatives and neighbor. So there seemed no problem in visual perception and she had no visual perceptual deficit. There were no hallucinations, disassociation and visual agnosia.
She was able to repeat what was said to her. She was able to understand oral instructions given to her. She could easily differentiate between sounds of maid and other members . She understands the conversation and learning delivered at normal rate. So it seemed that she 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 her in telling the meaning of the words like house, Window and road. She pointed out her right/left body parts. She received the instructions easily. She also captured the sounds of different words easily.
The client’s expressive ability was understandable . At the starting of the assessment she was hesitate it seemed that she had difficulty in expressing herself in speech. She was not quite expressive. She not only gave answers to my all questions.
General Fund of Knowledge
The client seemed to have age appropriate and excellent general fund of knowledge.
Comprehension and Vocabulary
The client’s comprehensive ability seemed to be intellectual. She properly and reasonably answered all the questions and coveys whatever were asked to her like she appropriately answered the question like , what you would do if someone cheats you? However her vocabulary was average as she was able to spell some words like enhancement, recognition, lecturers and spirituality. She seemed to be unwilling to engage in the tasks related to vocabulary.
The client’s abstracts reasoning was relevant. She could easily told similarities and differentiates the things for example similarity between crow and sparrow and differentiates between two things like river and canal, difference between landline and cell phone she readily did so.
Short term memory
Her selective attention was well . She could memorize the name of the institute in which she was living on that time, her dinner that she had taken in the last night, and breakfast in the morning. She also can recalled the date, month, day, year etc.
Long term memory
Her long term memory also seemed to be upright. She was able to memorize her early school days. She successfully recalled her home address and birth day herself and her family members. She also memorized the incidents concerning to her past life There was no severe retardation and any forgetting disorder .
Attention and Concentration
The client’s attention and concentration seemed to not distractible. She remained attentive during sessions but sometimes lost interest while being questioned.
The client seemed to be a well oriented towards time. When asked her about the time she correctly answered to these questions. She told me the correct time, year, season, date, day and month.
She was very oriented about person because she correctly answered the question about the neighbor girl who passed by the room.
She also seemed to be well oriented towards place.
The client seems to have a true insight of his problem. She knows she suffered a lot due to her relationship problems.
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.
- Otis Quick Scoring Mental Ability Test
- House tree person test ( H-T-P)
- The Self Image Profile for Adults (SIP-AD)
- Rotter’s Incomplete Sentences Blank (RISB)
- The Beck Depression Inventory (BDI)
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.
|Raw score||Constant added||Standard score||Range||Category|
The client’s raw score is 30 and after adding a constant of 72 for the age range of 23 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 she has an average intellectual capacity.
House –Tree – Person test (H-T-P)
House – tree –person (H-T-P) was administered to assess the personality of the client. The results revealed feeling of depression, insecurity, withdrawal, inadequacy and discontentment.
The house drawn by the client reveals that there are withdrawal tendencies in her. She drew a large house on the left side of the page which reflected withdrawal symptoms that indicates her feelings of restrictive environment and tension. Low placement of house is an indicative of client’s fear, insecurity and avoidance of conventional environment. The large door drawn by him is a sign of her dependency. Light quality of lines also suggests weak ego strengths and sense of insecurity . quality of light implies hesitance and insecurity
The client drew a tree that was moderate in proportion and is an indicative of her inferiority complex and insecurity. The crown of the tree was clouds alike and it revealed her fantasy and guilt feeling about her past mistakes . The Narrow trunk drawn by the client reflects that she had not control on her . Omitted roots are also sign of her sense of insecurity
The client also drew a person (girl) of small size that shows her feelings of insecurity and discontentment. Low placement of the girl drawn suggests concreteness, depression and feelings of insecurity. The drawing also shows a feeling of inferiority and rigidity. The small eyes reflect the client’s introversion and apprehension. The thin and weak arms and legs reflect strong feelings of hopelessness. Buttons on clothing reflects client’s immaturity. Omitted feet reflect her helplessness. Line quality used in drawing was light that reflects client’s hesitation.
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)
|Time Taken||Raw Score||Range||Category|
|15 min||21||14 – 19||Mild Depression|
The client’s raw score on BDI is 21 which fall within the category of mild depression (14 -19). The results of test revealed that the client is suffering from mild depression.
The Self Image Profile for Adults (SIP-AD)
The Self Image Profile for Adult (SIP- AD) is a brief self –report measure that was administered to the client to provide a visual display of both her self-image and her self-perception. It invites the client to consider both “ How she is’’ and “How she would like to be”. The sum of discrepancy score showed her level of self-esteem.
The results obtained are as follow:
Table Showing Scores of the Self Image Profile for Adults (SIP-AD)
Client has scored as low self-image as his raw score was less than cut-off scare . she also have low self-esteem because his raw scored was high than cutoff score .
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
|Percentage of Conflict Response||Percentage of |
|Percentage of |
|Percentage of |
Table Showing Cutoff Point of RISB
|Client’s Total Score||Cut off Point|
The result shows that 55% of client’s response were conflicted and this personage indicated a negative and maladjusted frame of mind . 45% of client responses were positive which reveals that she also have some positive view about her life .
The client’s total score on RISB is 138. The cutoff score 135. This reflects that client’s score is above than the cut-off point and it shows that her personality is not adjusted.
The client seemed to have pessimistic attitude towards her family. There seemed to be strong feeling of withdraw.
Social and sexual attitudes:
The client’s responses to various items suggested that she had a negative social attitude. She wants to remain alone. Her general concept about people seemed to be quite negative attitudes.
The client’s attitude towards seems positive .
The clients had a negative approach towards life. However she has both positive and negative views about herself.
Identification of Problem
The client was living with her father and step mother after the death of her other . After her mother’s death she had faced many problems. The client was sad, anxious and worried about her condition as she started taking drugs her health also effected and more important her family behavior became more worse towards her . As she did not see any hope signs of better situation and think that it could even more worse leads her to hopelessness.
The client seemed to be a case of mild depression and have a very low and poor self-image about herself. She have adjustment problem in different relationships like father- daughter relationship, romantic relationship etc. and very resistant to change. The client is a 21 years old young girl belongs to an upper middle class family. Her problem started when she comes to his parents after long time. She was not properly adjusted with her parents and she was also not adjusted in her college and low interaction and interpersonal skills decrees her self-esteem and her self-image become poor day by day. According to the Monoroes ,rohole andSeeley ( 2001 ) romance failure, and failure at interpersonal relationship cause depression. This research is quite relevant to the client case as her depression also caused by relationship failure.
Gotlib, Gotlib and robinson ( 2000) suggested that depressed people are low in social skills across a variety of measures such as interpersonal problem-solving, speech pattern and maintenance of eye contact. The client also have lack of social skills and that’s why she was speaking very slowly and has difficulty in making eye contact in the beginning.
A recent study on depressed children found a significant yearly decrees in their grade point average as compare to non-depressed sample (McCauley & Moss, 1999) the research is applicable in Client case as reported by the client’s teacher her performance in the college.
Gotlib and leo ( 2002 ) found that depressed people have smaller and less supportive social network . than do non depressed people they know fewer people interact with them less often and consider them to be less supportive this is relevant to case because client has smaller and less supportive social network and now she lost her interest in people .
According to research people who have poor interpersonal skills and weak family relations have more chances to become an drug addict as compare to those who have good family relationships (Gotlib and leo ( 2002 ).
In the client case as she has low self-image about herself and poor interpersonal skills and have weak family bonding she started taking drugs to avoid the disturbance and her academic performance is also affected by this. All this stuff leads her to depression and hopelessness about her future and her current condition. She thinks her image is spoiled and it can never be bettered now all this indication of low self-image.
There are several types of treatment to deal with drugs addicts. There are several medicine which could help them to overcome this addiction and she also need proper health checkup and should improve her diet.
In the client’s case the interpersonal and social relationships are the main source of depression. According to interpersonal theory depression can often be traced to the broader social structure in which people live and the roles they are required to play. This type of treatment is valuable for the client to resolve such problems. Interpersonal therapists believe that many depressed children have experienced much disrupted relationships (as in the case of many client) and they fail to establish intimate relationships as adults. Interpersonal therapy may help the client to learn new social skills and assertiveness in order to improve her social effectiveness.
Behavioral Therapy (Social Skills Therapy):
Behavior therapy is necessary for the client because she has feelings of worthlessness, loneliness and social withdrawal. Moreover the client is not socially active and is not interested in other people , through this approach the client can be made socially active, responsive and to adopt realistic criteria for performance. Social skills training is one of the primary behavioral techniques used in the treatment of depression. Behavior modification could also help her out to get rid of addiction.
Social skill training
Social skill training is normally consisted of four parts.
Firstly, the client is taught basic verbal and non verbal skills that focus on small segments of the desired behavior. Secondly, after rehearsing these segments with the therapist the client is then given homework assignments in which the goal is to adopt the new skills so they will become useful for the client in her every day environment. Thirdly, the client is trained to be more perceptive about cues other people give in the environment and learn how to change her behavior according these environmental changes. Fourth, Finally the client learns to adopt realistic criteria for performance and is taught how to be self-reinforcing.
Problem solving skill training
Problem solving skill training is easy for client to learn and she can apply it to a variety of difficult problems such as academic difficulties and relationship problems.
Cognitive Behavioral Approach
Role rehearsal or role playing is one of the cognitive behavioral techniques. Through this technique the client can be taught how to deal and handle the situations that are thought to be difficult e.g. dealing with her hostel fellows and class mates. Here the therapist can act as a model to show the clients who feel overwhelmed to their lives.
Rational Emotive Imagery
In order to overcome the inappropriate thinking and feeling of client rational emotive imagery can be used . this kind of mental practice can be helpful for the client to established new emotional patterns . n REI the client is asked to close their eyes and to re-create that problematic situation in their mind’s eye, then to experience the emotion. The client is then encouraged to change the emotion (created by the demand). For some clients, rising above and more objectively and philosophically identifying the emotion for one minute and then changing their view or beliefs about the situation silently through their own self talk, – and often acknowledging that she/he may not like that emotion or the situation but they can accept that initial feeling and unconditionally accept themselves – they find they have changed the unhealthy emotion and are experiencing a healthier one.
Self-esteem building technique provided by Spett in 2005 in Jersey Psychological Association Conference in a workshop named “CBT for Low Self-Esteem”.
It includes identifying patient’s low self-esteem components. In every session, asking about specific situations which recently evoked the patient’s low self-esteem. Then it includes expressing self-acceptance cognitions, correct invalid criticisms, and misperceptions of weaknesses, mistakes and failures. It also includes asking patients to imagine upcoming situations that may evoke their low self-esteem components, having patients prepare and rehearse self-acceptance cognitions they can be used in these situations.
- The client must have good and healthy home environment. Her family member should support her at every step.
- Her mother as well as her siblings should take great care of her very well and pass as much time with her so that she can it feel lonely in her house and differences between them should be sort out.
- The client need social support from her family in order to make her point of view positive towards the people and trust can be developed on the client about her family and relatives.
- There is a need to work on the self esteem and the self image of the client as due to clashes with her step mother and step sisters and they negative attitude her feelings was badly affected.
As the client is facing emotional difficulties which are her interpersonal problems. It is important to prevent the client ‘s feeling of inferiority and low self-image. The client showed symptoms of depression so in order to cope with it and in addition to biological and psychological therapies, the following light sort of strategies are recommended to client. The client must have good and healthy home environment. His family member should support her at every stage Her mother as well as his sibling should take great care of her very well and pass as much time with him so that he can’t feel herself lonely in the house. She needs to be close with her family, she need needs their time, affections and love.
He client needs social support from his family in order to make the point of view positive towards the people and life and trust can be developed on the client about his family. There is a need to work on the self-esteem of the client.
As the client has changed his school two years back so it was difficult to gathered detailed information about his academic performance in previous school.
During the testing sessions the Client was repeatedly distracted by the outside noises so the results of psychological testing cannot be considered as significant.