Major Depressive Disorde

1. Case Report I
Identifying data
Name: M.A
Age: 21
Gender Female
Education M.A
Siblings 4(2Brothers, 2 Sisters)
Marital Status Un-married
Informant Mother
Ward In-patient
Total no. sessions 4
Initial date of session February 21 2022
Last date of session February 28,2022
Source and reason for referral
Client was referred to the trainee clinical psychologist with the problems of
sadness, loss of pleasure due to which she referred to Chaudhary hospital by the help of
physician of psychological assessment and treatment.

2. Presenting Complaints
 According to client
‫عالمات‬
‫۔‬
‫دورانیہ‬
(
1
‫س‬ ‫سال‬
)‫ے‬ ‫ہے۔‬ ‫نہیں‬ ‫خوشی‬ ‫جیسی‬ ‫پہلے‬ ‫میں‬ ‫زندگی‬
(
10
)‫سے‬ ‫ہ‬ ‫ما‬ ‫لگتا۔‬ ‫نہیں‬ ‫دل‬ ‫میں‬ ‫چیز‬ ‫کسی‬
(
7
)‫سے‬ ‫ہ‬ ‫ما‬ ‫آجاتاہے۔‬ ‫جلدی‬ ‫غصہ‬
(
6
)‫سے‬ ‫ماہ‬ ‫آت‬ ‫بہت‬ ‫نیند‬
‫۔‬ ‫ہے‬ ‫ی‬
‫۔‬ ‫ہوں‬ ‫تی‬ ‫کھا‬ ‫بہت‬ ‫تو‬ ‫ہے‬ ‫لگتی‬ ‫جب‬ ‫لیکن‬ ‫لگتی‬ ‫نہیں‬ ‫بھوک‬
(
6
‫سے‬ ‫ماہ‬
)
 According to informant (Mother)
‫دورانیہ‬ ‫عالمات‬
( ‫۔‬ ‫ہے‬ ‫رہتی‬ ‫اداس‬ ‫وقت‬ ‫ہر‬
1
) ‫سے‬ ‫سال‬
‫بیٹھتی۔‬ ‫نہیں‬ ‫ساتھ‬ ‫کے‬ ‫والوں‬ ‫گھر‬
(
8
)‫سے‬ ‫ماہ‬
( ‫۔‬ ‫ہے‬ ‫رہتی‬ ‫میں‬ ‫کمرے‬ ‫وقت‬ ‫ہر‬
8
)‫سے‬ ‫ماہ‬
( ‫۔‬ ‫ہے‬ ‫ہوگئی‬ ‫کمزور‬ ‫بہت‬ ‫سے‬ ‫پہلے‬
6
) ‫سے‬ ‫ماہ‬
History of Present Illness:
Miss M.A was came with the complaint of depression. She has the complaints of sadness,
hopelessness, worthlessness, fatigue, irritability and headaches. First episode occur when she
was in the Matric, her father was suffered from a bike accident and admit in hospital for 2
months. He lost his blood and injured. She was very upset and fear that what happen, if her
father die? After two months her father recovers his injury and discharged from hospital. But she
still feared that what will happen if her father will die. She has treatment from a doctor. Second

3. episode occur when her uncle die. She depressed again and always thinks that what will be
happens to the children of her uncle. She falls ill. She was comes to hospital for treatment.
Background information
Personal History
The client was 21 years old girl and her education was M.A.. She loved the company and
attention of family and friends and enjoyed the outings before the illness but now she want to
live alone. She was food lover and enjoyed fast food. She loved gossips. She did not like to
watch dramas, movies and was not found of social media. She spent all the time at house and
took care of house and perform all household responsibilities, sometimes she went to her
neighbors and spent time with them. She was very active and energetic in her childhood.
Education History
According to the client she started the school at the age of 4 years. She got first admission
in a private school. She was a good student. According to client’s teacher of that school were
nice and lenient. She did her matriculation at the age of 16 years old. Then she want to study as a
private student. She did her intermediate and graduation in Allama-Iqbal Open University
Islamabad. Now she was the student of M.A political Science. She got the religious education at
the age of 4 years and completed at the age of 8.
Social History
According to the client, when she was studying in school, she has many friends. Now she
has only neighbor’s sibling friends. She had no social relation interaction with people. She has
untoward personality type.
Family History

4. According to client, her father was a teacher and a pious man. He was 53 years old. He
loved her and support her. He was graduated and school teacher. He was retired 5 years ago. He
was a good painter also. He loved and cares his family. He fulfilled his children’s desires. The
home environment was so loving and cool. The client loved her father’s personality and had
strong interaction with her.
Her mother was a house wife and 46 years old. She was a great lady and cares her family.
She guided her children in all matters. According to client her parents had a good relationship.
The client had 5 siblings as 3 brothers and 2 sisters. Her elder brother and elder sister were
married. Her younger brothers were getting education. Her brothers were dominated and
authoritative, which makes the client irritative and depressed as well as the home environment as
aggressive.
Sexual History:
Client had puberty at the age of 14 years and had a regular menstrual cycle. She was at
the peak of sexual energy from her teenage but when she became depressed her periods begin
irregular.
Psychological Assessment:
Psychological assessment is a process of testing that uses a combination of techniques to
help arrive at some hypothesis about a person and their behavior, personality and capabilities.
Psychological assessment is also referred to as psychological testing or performing a
psychological battery on a person. Psychological testing is nearly always performed by a
licensed psychologist, or a psychological trainee (such as an intern). Psychology is the only

5. profession that is expertly trained to perform and interpret psychological test. (Framingham,
2016).
PREMORBID PERSONALITY:
According to client, she had good relationship with family before her illness. She loves
her family a lot and family loved to her. She was neglects by her relation after the onset of the
disorder. According to the client she had no achievement and life goals. She was really wants to
stayed alone and live like this forever. But now, she wants to overcome her disorder and wants to
make new friends and enjoy life. She was feels that life is precious thing and it should be
enjoyed. She was says that she had no achievement in her life.
The assessment procedure was done through two levels:
1. Informal psychological assessment.
2. Formal psychological assessment.
Informal Assessment:
Informal assessments are those that are used to evaluate a student’s own performance and
progress individually. In the classroom, these take numerous forms and are simply the teacher’s,
student’s and parent’s way of measuring that student’s progress (Greaver). Observation,
checklist and portfolios are just some of the informal methods of assessment available to early
childhood education (Morrison, 2013).
Following informal assessment techniques were used.
 Clinical interview

6.  Mental status examination
 Behavioral observation
Clinical interview
The clinical interview is foundational to psychological or mental health treatment. It
involves a professional relationship between a mental health provider and a patient or client and
is used across all major mental health treatment disciplines.
The clinical interview was conducted to acquire information regarding the patient’s
history including history of present illness in an informal method. The first step included
gathering details about the nature of patients’ problems and symptoms. It also included personal
history, educational history, socialization, vocational history and sexual history. It was ensured to
the client that privacy would be maintained.
Behavioral observation
Behavioral observation is useful for the assessment of persons with limited verbal
abilities, the measurement of persons' behavior in their natural environments, and the
measurement of functional relations among contemporaneously occurring behaviors and
environmental events.
The client was 23 years old. She was looking a bit depressed. Her dressing style was
good. She wearied neat and clean clothes. She remains normal in the sessions but later her mood
become normal and she also passed smile some times. She was cooperative, according to her the
tests was not much difficult and most of her feelings present in the tests.
Mental Status Examination

7. A type of clinical interview often used in clinical settings, the primary purpose is to assess
quickly how the client is functioning at the time of evaluation. (Pomerantz, 2014). It is a structured
way of observing and describing a patient's psychological functioning at a given point in time,
under the domains of appearance, attitude, behavior, mood, and affect, speech, thought process,
thought content, perception, cognition, insight, and (Trzepacz & Baker, 1993).
General description:
M.A presented as well groomed, appropriately dressed young woman who looked older
than her age. She was articulate and able to give a good history. However, there was obvious
tension between her and her family after the onset of depression. When seen on her own, M.A
was articulate and able to give a good history. She described having been unhappy every day for
some time; she had lost interest in everyday activities and pastimes, had recurring thoughts that
she may be better off dead, mainly after the death of her uncle. Her school performance,
concentration and motivation had deteriorated also. She was sleeping and eating more than usual.
She denied and there was no evidence of hallucinations, delusions, obsessions or compulsions.
She seemed of average intelligence but was not formally tested. M.A appeared to have some
insight into her behavior and prepared to attend treatment. Her memory was not too much good.
She scored in the severely depressed range in a depression rating scale.
Formal Psychological Assessment
` Formal assessment methods are considered to be more objective and they can be used in
clinics, schools, private practices and residential treatment facilities in conjunction with other
measures to aide with eligibility issues, diagnosis, educational placement, and decisions
regarding intervention processes. Normally, formal assessment methods get used to acquire

8. evidence that supports conclusions that are made from the test. One example of this could be if a
clinician uses this method to confirm that a client’s reading ability is below average. This could
also be accomplished because there would be visible evidence to support the fact that the clients
scores fell in a below average range for that particular age group (Cohen &Swerdlik, 2010).
The functioning of various areas of personality has been assessed by;
 Diagnostic assessment
a. Beck Depression Inventory (BDI)
 Personality assessment
a. Rotters Incomplete Sentence Blank (RISB)
b. HTP
Diagnostic assessment
BECK DEPRESSION INVENTORY (BDI)
The Beck Depression Inventory (BDI) was used to measure the severity of depression. It
is developed by Aaron T. Beck in 1961and copyright in 1979. A second version of the inventory
(BDI-II) was developed as a mirror revision in the Fifth Edition Text Revision of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-V-TR, a hand book that mental health
professionals use to analyze mental disorders).
The long form of BDI is composed of 21 questions or items; each question has a set of
4possible responses. Each commonly used instrument for qualifying items using 4 points. When
the test is scored is a value of 0 to 3 is assigned for each answer. And then the total score is
compared to a key to determine the severity of depression. The standard cutoff scores are as
follows.
1-16 indicates mild depression.

9. 17-29 indicates moderate depression.
29-above indicates severe depression.
Individual questions of the BDI assess the mood, pessimism, sense of failure, self-
dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability,
social with drawl, body image, working difficulties, insomnia, fatigue, appetite, weight-loss,
bodily preoccupation and loss of libido. Items 1to 13 assess more physical symptoms that are
psychological in nature, while items 14 to 21 assess more physical symptoms.
Test administration
The test was administered on client on in a well light room in hospital. The environment
of room was normal and it was not disturbed during the administration of the tests. She was
seated comfortably and instruction was given to her. She took 20 minutes to complete this test.
Behavioral Observation
During test client behavior was also observed. The client was 23 years old and her height
was 5.3. She was wearing neat and clean clothes. She was not too much talkative. She had good
eye contact during practical. Her voice tone was normal. The client reported that she generally
feel sad and depressed feeling due to this problem. Her memory was quite good. She was very
cooperative and responds all questions well.
Personality Assessment
Rotter Incomplete Sentence Blank (RISB)
The Rotters Incomplete Sentence Blank is a projective psychological test developed by
Julian B. Rotter in 1950. A sentence completion test design to measure psychological

10. adjustment, available in three forms (high school, college and adults), each consisting of 40
truncated sentence, such as I hate…; the best…; and most girl… Sentence completion are scored
in the scoring manual by assessing a numerical weight from 0 to 6 for each sentence and totaling
the weights to obtain the over-all score. It is differential for male and female. It is scored for
conflict, positive response, and neutral response, from which an overall adjustment score is
calculated.
Test Administration
Test was administered on 28 November 2018 in a well-lighted room in fountain hospital
Lahore. Room was noise free. The client was seated on a chair comfortably and instructions were
given to her. She took 30 minutes to complete the test.
Behavioral Observation
The client was 23 years old. She was not alert during the test, she was also confused.
Rapport was easily established.
1. Omission responses
Omission responses are designated are those for which no answer is given or for which
the thought is incomplete. Omissions are fragments are not scored.
2. Conflict responses
C1 or Conflict responses are those indicating an unhealthy or maladjusted frame of mind.
These include hostility reactions, pessimism, symptoms elicitation, hopelessness and suicidal
wishes, statement of unhappy experiences and indications of past maladjustment. The numerical
weight for the conflict responses are C1=4, C2=5 and C3=6.

11. 3. Positive responses
P or positive responses are those indicating a healthy or hopeful frame of mind.
Responses rang from P1 to P3 depending on the degree of good adjustment expressed in the
statement. The numerical weight for the positive responses are P1=2, P2=1 and P3=0.
4. Neutral responses
N or neutral responses are not falling into either of the above categories and scored as
N=3.
Quantitative Analysis
Table
Rotter Incomplete Sentence Blank (RISB)
Response category Correspondent Score Obtained Score
Conflict responses
C3 = 6 8 8×6 = 48
C2 = 5 12 12×5 = 60
C1 = 4 9 9×4 = 36
Neutral responses
N3 3 3×3 = 9
Positive responses
P1 = 2 6 6×2 = 12
P2 = 1 0 0×1 = 0
P3 = 0 2 2×0 = 0
Cut of scores = 135 Obtained score = 165

12. Table
Shows results of RISB
Age Raw score Cut of score Result
21 165 135 Maladjusted
Conclusion
The client obtained 165 scores on RISB which fall in maladjusted.
Qualitative analysis
Familial Attitude
The girl seems to have a strong relationship with her parents in item 35. She provides a
picture of full concern with father “my father is a great man”. She admired the importance of her
mother and in item 11 “a mother is a most valuable person”.
Social attitude
General social superfluity is suggested by such sentence completion as item 7, 10, 15, 19
and 26. In item 7 “boys are aggressive”, item 10 “people are not equal”, item 15 “ I can’t talk
back previous time” and in item 19 “other people should not selfish”.
General attitude
She state in item 10 and 40 about her concerns towards others which shows her unhappy
experiences, “people are not equal” and “Most girls are very talkative.
Characteristics traits
Subject responses are unsatisfactory and negative towards her life item like 21, 20, 33
and 39 show her pessimist character like “I am so sensitive”, The only trouble is “people are not
supportive”, “Most girls are very talkative”.

13. Conclusion
Hence, she is maladjusted in her social attitude as well as in characteristics traits. She
sees her self as maladjusted.
House Tree Person (HTP)
John N. Beck developed HTP in 1948 & update in 1969. It is a projective test designed to
measure aspect of personality. The House-Tree-Person Drawing test (HTP) is an exam for
estimating self-perception and attitudes of a person through drawings, which act as the
ambiguous, abstract or unstructured stimuli. In addition, a projective technique like HTP
interprets drawings & provides questions that may rapidly assess the personality of the patient.
According to the John, houses and trees reveal the person’s inner identity responses given by the
client introduce a more perceptive view of the person’s personality. This test expresses the inner
feelings of the subject.
Test administration
The test was administered in a well light room in fountain hospital. There was no noise.
The client was sitting on chair. The instructions regarding test was given to client. She took 15
minutes to complete the test.
Behavioral observation
The client was 23 years old. The rapport was easily established & maintained maintain
her alertness.
Interpretation and analysis
HTP can interpret qualitatively only. Qualitative analysis given below:

14. House Interpretation
She had drawn a medium size and on right side house which indicates expectations with
especially mother symbolically. Absence of windows showed that she had withdrawal tendency
and like to be social and small doors may suggested she felt socially inadequate and indecisive
and closed door showed that she did not like to going outside. Individual also draw chimney
which showed that client feels psychological warmth in the home. Path is surrounded a house
shows a barrier or protection. She had drawn the single line of roof which indicate emotional
disturbance. And close door reject to willingness and openness behavior.
Tree Interpretation
The individual had drawn a tree on the center the page. She draws the cloud like tree
which indicate active fantasizing in a childish avoidance of reality. She had drawn bleak
branches structure which indicates perceived environment as unhappy, absence of leaves showed
lack of ego integration and inner barrenness and dead trunk showed that perceives a loss of ego
control in obtaining satisfaction from environment. Poorly organized root and baseline indicated
that emotionally unstable, feeling of insecure and poor general functioning. Individual had drawn
a tree which is not representing any particular genetic type.
Person Interpretation
The client draws a person on upper side of the page which indicates high level of an
active fantasy life. She draws a large head which indicates a person’s aggressive and self-
centered behavior. Mitten type hands suggested that feeling of guilt. Omissions of ears show the
auditory hallucination and minimize contact with environment. She draws hairs which indicate
that virility striving, sexual, preoccupation. Mouth suggested guilt related areas of oral conflict.
She had drawn arms which indicate feeling of inadequate, powerless or ineffective and asocial in

15. the world. Short and thin legs suggested that she has lack of autonomy. Omissions of feet
suggested that dependent and helpless feeling. She draws stick figure that reveals excessive
tendencies, insecurity and problems with interpersonal relationship.
Conclusion
After interpretation of House Tree and Person drawn by client reflects that she has feeling
of inadequacy and inferiority. And she has feeling of worried and maladaptive behavior tension.
Tentative Diagnosis
Client might be diagnosed according to the DSM-5 check list Major depressive
disorder300.4 (F34.1).
Psychological and Environmental Factors
Sadness, loss of pleasure, feeling of worthless is the psychological factors and separation
of her uncle, home environment and her father’s accident is the environmental factors.
Differential diagnosis
If there is a depressed mood plus two or more symptoms meeting criteria for persistent
depressive disorder episode for two year or more. Where the major depressive disorder
diagnosed on the basis of 5 or more symptoms including sad mood or loss of pleasure and the
persist for at least 6 months.
Persistent depressive disorder distinguish with bipolar or cyclothymiacs disorder in
persistent disorder just depressive symptoms present not manic or hippomanic symptoms present
and to diagnose the bipolar disorder it is necessary client having manic or hippomanic
symptoms.

16. Dysthymia distinguish with Disruptive Mood Dysregulation Disorder key feature of this
disorder mood in consistent e.g. aggression toward people or property that are out of portion and
duration of this disorder 12 month or more and 3 months consecutive with symptoms.
Prognosis
In the case under discussion client has bad prognosis due to her family especially her
brothers. The factor that support the bad prognosis are gender, more worrying about future and
sadness which was faced by the client. Her brothers were so authoritative and aggressive which
create irritation for the client but her mother and father was too much caring and loving that had
some chances of good prognosis. Other factors like home environment that also contribute
toward bad prognosis not being able to stay calm and cool, fear and sleep problem.
Feeling of hopelessness leads toward the bad prognosis according to hopelessness theory
(Abramson,Metalesky 1989). Is the most important factor trigging the depression hopelessness
describe that desirable outcomes will not accurse which is defined by the symptoms of sadness,
decrease need of energy ,psychomotor retardation, sleep disturbance and negative cognition.
Client has insight about her problem and the also recognize that due to this problem other
important areas of life was also disturbed. This factor leads toward the good prognosis. Client
belongs to a middle class family, but there was no problem of money which is necessary for
client treatment.
Case formulation
Client was 23 year old female. She belongs to a middle class family. She comes here
from city Gujranwala due to the symptoms of hopelessness, worthlessness, fatigue, irritability,
uncontrollable the worries and lack of interest in life in daily routines for the purpose of

17. psychological assessment and psychological treatment . Psychological assessment is conducted
through formal and non formal assessment. In formal assessment Clinical interview, Mental
Status Examination (MSE), Behavioral observation and Visual analogue were used. House-Tree-
Person (HTP), Rotters Incomplete Sentence Blank (RISB) and Beck Depression Inventory (BDI)
were used in formal psychological assessment. She was suffering from Major Depressive
Disorder (MDD). Her illness was started from 2 years ago. According to the client she had this
problem due to over sensitivity about everything. The management techniques were planned to
manage her symptoms.
Predisposing factors
Predisposing Factors the cognitive model present a hypothesis about the predisposition of
depression. The theory proposes that early experiences provide the basis for forming negative
concept about oneself, the future and the external world. These negative concepts can be latent
but can be activated by specific circumstances which are analogous to experiences initially
responsible for embedding the negative attitude. As the client home environment was aggressive
and after the death of her uncle she develop negative attitude about everything (Beck, Rush, Saw
& Emery, 1979). Gender may also play a role in depression. The life stress theory suggests that
women in our society experience more stress than men (Astbury, 2010; Keyes & Goodman,
2006). On average they face more poverty, more menial jobs, less adequate housing, and more
discrimination than men all factors that have been linked to depression. And in many homes,
women bear a disproportionate share of responsibility for child care and housework.
Precipitating factors
The precipitating factors for the client were the domestic problems including the financial
issues, problem of her uncle’s death as well as home’s distress environment. When the individual

18. had limited financial resources are unable to meet their needs which trigger in them, people with
low incomes are twice as likely as people with higher income to experience the disorders.
Perpetuating Factors
The perpetuating factors in this case were the loneliness and sadness at home, negative
thinking and worthless. Loneliness is a unique risk factor for depressive symptoms in middle-
aged to older adults. Growth models revealed reciprocal influences over time between loneliness
and depressive symptomatology. Client negative thinking that’s had no worth in her family is
also the cause of her symptoms. Aaron Beck believes that negative thinking lies at the heart of
unipolar depression.
According to Beck, maladaptive attitudes, a cognitive triad, errors in thinking and
automatic thoughts combine to produce the clinical syndrome. That thinking typically takes three
forms, which he calls the cognitive triad: the individuals repeatedly interpret (1) their
experiences, (2) themselves and (3) their futures in negative ways that lead them to feel
depressed.
According to psychologist Martin Seligman (1975) feelings of helplessness are at the
center of her depression. It holds that people become depressed when they think they no longer
have control over their reinforcements (the rewards and punishments) in their lives. These are the
factors that made her feel alone and more stressed. Therefore, her feelings of depression kept
constant despite her efforts of being normal.
The protecting factors were the supportive attitude of client’s sister, her intrinsic
motivation to recover from depression, desire to return to her normal routine and be happy and
healthier Person.

19. Name M.A
Age 28
Presenting Complaints
 Sadness
 Worthlessness
 Sleep difficulty
 Loss of pleasure
 Loss of energy
Predisposing
Factors:
 Gender
 aggression
 Home
environment
Perpetuating
factors:
 Sadness
 Worthless
 Negative
thinking
Precipitating
factors:
 Home
Distress
 Death of
Uncle
Protective
Factors:
 Mother
 Intrinsic
motivation
Assessment
 Behavioral observation
 Clinical Interview
 MSE
 Beck Depression Inventory
Major depressive
Disorder
Management:
 Psycho-education,
Rapport building,
problem solving.

20. Figure I: Case formulation according to Bio-Psycho-Social
Model

21. Management plans
Management planning is the process of assessing and organization’s goals and creative
realistic, detailed plan of action for meeting to those goals.
 Rapport Building
 Relaxation Exercise
Rapport Building
Building rapport is the process of developing that connection with someone else.
Sometimes rapport happens naturally. However, rapport can also be built and developed
consciously by finding common ground, and being empathic. A good rapport was developed
with the client. A comfortable environment was presented to client. In initial, questions of her
interest were asked. She was asked to share her common interests, her likes and dislikes were
asked.
Relaxation techniques
Relaxation techniques are a great way to help with stress management. Relaxation isn't
only about peace of mind or enjoying a hobby. Relaxation is a process that decreases the effects
of stress on your mind and body. Relaxation techniques can help you cope with everyday stress
and with stress related to various health problems, such as heart disease and pain.
Deepbreathing
Deep breathing helps Anxiety and Depression. Deep breathing has been proven to help
with wellbeing tremendously. Coherent breathing involves breathing at a rate of 5 breaths per
minute. It is suggested that this can be achieved if you count to 5 inhaling and count to 5
exhaling.

22. Find Motivation
You're much more likely to stay motivated if you're working towards something that you
genuinely want to do or achieve, rather than what other people want for you. Find things that
interest you within goals that don't. So, try and find something within that task that does motivate
you.
1. Set goals. 2. Choose goals that interest you. 3. Find things that interest you within goals that
don't.4. Make your goal public. 5. Plot your progress. 6. Break up your goal. 7. Use rewards. 8.
Don't do it alone.
Proposed Management Plans
A management plan provides researchers the opportunity to explain the objectives goals
and planned procedures of their proposed projects in detail.
 Short term goals
 Long term goals
Short Term Goals
 The core of the interpersonal psycho therapy is to examine major interpersonal problems,
interpersonal conflict, bereavement, and interpersonal isolation. And makes important
session, and make changes to resolve problems related to the issues.
 Psycho education therapy to aware the family members and other people in relation to the
client.
 Relaxation exercise will be used to help her to overcome her muscle tension, to calm
down her anxiety and to improve quality of sleep.
 Daily activity schedule will be used to get her busy, and to give her a structured
environment.

23.  Dealing with sleep difficulties.
Long Term Goals
 Follow up sessions to be continued to monitor and assess the patient’s functioning.
 Cognitive restructuring to change client’s way of thinking.
 Encourage the patient to have discuss her problematic issues in future and thus to sustain
her recovery.
 Improve physical functioning due to development of adequate coping mechanism for
stress management.
 Family therapy session will be arranged to assist the family members increase their
positive support of the client.
Summary of the therapeutic interventions:
Interpersonal psycho therapy
Interpersonal psychotherapy builds on the idea that depression is closely tied to
interpersonal problems. The core of this therapy to point out major interpersonal problems e.g.
role transition, interpersonal conflict, bereavement, and interpersonal isolation. Typically
therapist and patient focus on one or two such issues, with the goal of helping the person identify
his or her feelings about these issues ,make important decision , and make changes to resolve
problem related to these issues. IPT techniques usually discussing interpersonal problems,
exploring negative feelings and encouraging their expression, both verbal and non verbal
communication improving, problem solving , and suggesting more satisfying modes behavior.
The client can be helped by using a number of therapeutic interventions, some of which are as
follows:
Psycho-education

24. Psycho education is of deem importance starting psychological treatment of anxiety as
well as other disorders. Education provides a knowledge base that gives the individual greater
control over the disorder.
Psycho-education refers to the education offered to people who live with a psychological
disturbance. It takes place in one-on-one discussion or in groups by any qualified health educator
as well as health professionals. It consists of giving patients and their relative’s adequate
knowledge about disorder and teaching illness self management skills so that people have a
better understanding of their illness and its treatment.
Several steps will be involved in psycho-education. At first level, patient and her family
will be educated. Awareness about disorder, early detection of warning symptoms and adherence
with treatment will be given to client’s family. At second level, the patient and family is
educated about controlling stress achieving regularity in life style. At third level, patient and
family will be asked to improve social and interpersonal activity for well beings and improving
the quality of life.
Relaxation technique
16 PMR (Progressive Muscle relaxation) techniques can be used to make the client relax.
In the first phase the client is told to tense each muscle group step by step before relaxing it. This
procedure will make the client aware of sensation associated with relaxation and will teach him
to differentiate between two sensation, pain and relaxation. This technique benefits the client
physically and psychologically.
Cognitive restructuring

25. In this technique clinicians try to change client’s way of thinking. In this way the target is
to change the negative and alarming thinking associated with the depressed symptoms (Zettle,
2004).
Problem solving
Problem solvingis another skill that helps the patient to effectively manage their depressive
symptoms. Often problem solving involves engaging in an activity and can become a part of
behavioral activation plan
Cognitive therapy attempts to counter negative thoughts and errors in logic. There are
four specific cognitive therapy techniques that are used: detecting automatic thoughts, reality
testing automatic thoughts, reattribution training, and changing depress genic assumptions.
Cognitive therapy helps patients to identify automatic thoughts. Once a patient has
learned to identify such thoughts, the cognitive therapist engage in a dialogue with the patient in
which evidence for and against the thoughts is scrutinized
Limitations and suggestions
Limitations are as following:
 Time period for building rapport with the client was very short.
 Administration of tests was difficult due to continuous interruption by other patients in
ward and paramedical staff.
 Only one informant was available throughout the assessment. Information from other
family members could not be collected which could helpful in identifying more.
Suggestions are as following:
 Assessment should be carried out in a *room or open environment that is free of
distractions.

26.  Time period for case study should be extended.
 Information should be gathered from all the people in close contact of the client.
Session Report
SessionNo 1: Dated: 14 February, 2022
It was an introductory session, in which the general problems of the client were
discussed, and the objective of communication was shared by the client. This session took about
20 minutes.
SessionNo 2: Dated: 17 February, 2022
The purpose of this session was to develop a rapport with the client so that he may feel
comfortable and share her all information confidently. Basically in this session clinical interview
was taken in which questions of client’s interest were asked, about likes, dislikes, hobby, interest
and daily routine of the client. History of client’s present problems was also taken that which
factors contribute to trigger the problem. This session took about 50-55 minutes.
SessionNo 3: Dated:21 February, 2022
In this session Mental status examination Personality tests such as HTP and RISB were
administered. This session took about 40 minutes.
SessionNo 4: Dated:28 February, 2022
In this session Beck Depressive Inventory (BDI) was administered for the Assessment of
Major Depressive Disorder. At the end of session client was shared with some management
plans to cope up with disorder such as Relaxation Technique and Problem Solving. This session
took about 25 minutes.