ramesh psychotherapy.pptx

SOCIO DEMOGRAPHIC DETAILS
Name: MR. YS
Age: 33 years
Sex: Male
Education: CS and LLB
Occupation: Working as a Corporate Advocate
Religion: Muslim
Socio Economic Status: Middle Socio Economic status
Place of Residence: Urban
Informant: Self and Sister
Information: Reliable and adequate
Source of Referral: City Nursing home
Reasons for Referral: Psychological Evaluation and Psychotherapy
2

CHIEF COMPLAINTS
Client’s Version
 Feeling anxious
 Feeling of guilt
 Hopelessness
 Sadness
 Impaired sleep
 Low appetite
 Lack of concentration
 Thought of Suicide (One Attempt)
3

Sister’s Version
•Not able to sleep
•Excessive crying
•Thinking about his marriage
Duration: 4 months
4

Nature of Illness:
Onset: Insidious
Course: Continuous
Progress: Deteriorating
Predisposing Factor : Nil Significant
Precipitating Factor : Breakup of engagement
Perpetuating Factor : Nil Significant
5

HISTORY OF PRESENT ILLNESS (HOPI)
 Mr. YS, 33 years old, Muslim male hailing from urban middle class brought
by his sister with the chief complaints, Feeling anxious, feeling of guilt,
Hopelessness, Sadness, Social Isolation, Impaired sleep, Low appetite, Lack
of concentration, Thought of suicide.
 Patient started his schooling at age of 6years. He is completed his education
up to CS and LLB.
 Patient is good in academics. (From Primary to higher education).
6

HISTORY OF PRESENT ILLNESS (HOPI)
 The client was apparently well until August 2021. According to the sister the
problems started after 3-4 months of engagement. He got engaged in
September 2021, and both sides of his family approved..
 The girl works as one of the academic director in her own institution
(School) and is also well educated. She also thinks highly of him. He also
thinks highly of her.
 After a month, they both started using Whatsapp to communicate, and they
began talking on their mobile devices in November2021. He made his first
visit to her house in the middle of December2021 for a getaway. Her family
members are joyful as well..
7

HISTORY OF PRESENT ILLNESS (HOPI) Cont….
 First meeting took place in a Hyderabad retail centre. Purchase some gifts
for one another, and spent time in a mall in January2022. Similar to how
ongoing weekly meetings are once or twice a week.
 In the month of February2022 he casually observed an audio recording on
her phone, which was of a male voice talking in a romantic manner. After a
few days, he questioned her about whose voice it was. She told him that
knew him and working as a faculty member at her institution.
8

9
 He is not happy with what she said and was suspicious on her. And he
began to feel depressed. After asking her repeatedly, she finally asked him
who that man was. But she gave the same response.
. In the month of May, she told him that she had also earlier been in another
relationship in the duration her bachelor’s course, which lasted for two years.
 After hearing about this, the client reported feeling sad and dejected, but
did not share with his family. Now that it's not there, break up. Client also
spoke to her ex-boyfriend, who had the similar response and he is currently
abroad, and after ten days claint also agreed.

10
His family members noticed his sadness during the month of May. His
sister and brother have repeatedly questioned him about what happened.
Yet he did not replay.
After a few days at the end of May2022, he gradually explained about
her. The news caused sadness among family members as well. In the
month of May2022. Though initially hesitant, he slowly opened up and
told them towards the end of May2022.
The client’s family members decided to break off the engagement in
June2022. His family members sent gifts to her house during the first week
of June2022.

11
Client cut off all contact with her. But sometimes she calls to him but he is not
answered.
From June onwards excessive crying and depressed and he changed three
companies from May to August because he couldn't concentrate on his work.
He was to the professional help by his sister.

NEGATIVE HISTORY
No history suggestive of
 Head injury
 Seizures
 Substance abuse
 Hallucination in any sensory modality, elated mood
 Mood symptoms etc.
12

PAST HISTORY OF ILLNESS
No history suggestive of any illness
13

Physical Illness:
Nil significant
Psychiatric Illness:
Nil significant
Details about family members:
Father is a farmer. Mother has passed away. The client has two ageing
brothers and one elderly sister, and they are married
Family History
14

Attitude of family members towards patient’s illness:
Client has reported that family is upset with his behavior.
Family Relationship:
The client has friendly relationship with his family members.
Present living conditions:
The client is staying with his sister's family in Hyderabad. There are four
members. They live in a rented house. His father was staying with his
brother's family in his home town.
16

 Overall, patient’s interpersonal relationship with family: He is
maintain good relationship with his family members.
17

PERSONAL HISTORY
Birth and Developmental: Normally conceived, 4th issue to non-consanguineous
parents. Birth was full term normal delivery at home. Birth cry was immediate and birth
weight was 2.7kgs. Developmental milestones achieved age appropriately.
Scholastic: As a child was join to school at 5yrs, but he was resistant to go to school. Than
he started going to school continually from 6yrs onwards. The client has maintained good
friendship from school onwards. He was good in academics. His performance is good from
primary school on wards. He is completed his education up to CS and LLB.
18

PERSONAL HISTORY
Occupational: The client first joined R. Sathyanarayan & Co. after completing his CS
and LLB courses for 3 years. After that, He went to R & A Associates for three years because
the pay had increased. Next, he joined in May 2022, PROGR & Co. He said he was unable to
focus on work, so company management removed him. In the month of June 2022, he joined
a new company but was also unable to do his job. Finally, in the month of August2022, he
began working as a Corporate Advocate for SANDOOR Medicates.
19

PERSONAL HISTORY
Marital & Sexual: The client is unmarried he has sexual knowledge gained through
friends and reading books. He reported that he never had any sexual relationships.
Habits: Watching TV and reading news papers and books.
Social: The client has maintained good friendships, but now he is communicating with fewer
friends.
20

PREMORBID PERSONALITY
The client is a very spiritual person. He does namaaz daily and he is very
helpful in nature. He is sensitive towards criticism.
Morals: Reportedly he is strictly bound to ethics and morals.
Attitude towards self: Client was hardworking, sincere, honest and loyal
person.
Attitude towards others: Helping nature.
21

MENTAL STATUS EXAMINATION
General appearance and behavior: Patient’s appearance were well kempt ,
Eye contact was present, Well groomed hair and rapport could be easily
established.
Motor Behavior: Motor behavior was appropriate.
Attitude towards Examiner: The patient was cooperative and attentive
throughout the examination.
22

Speech: The speech was coherent, goal directed, relevant.
Orientation: Patient answered correctly to current Season, Month, Date, Day
and year. He answered well with whom he came and where he was sitting.
Hence, he was oriented to time, place and person.
23

Attention and concentration: Attention measured throw digit forward and
digit backward method were he was able to do till 4 digits (forward) and till 4
digits (backward). In calculation he answered correctly.. Serial 8’ s and deduct
3’s from 40 and count backward. He answered.
24

25
Memory
Immediate memory- Immediate memory was already assed using digit span.
Recent- What did you eat last night (Chapatti and Chicken) - cross checked.
How did you come here. By bike. What did you eat for breakfast (Idly).
Remote- He was able to recall date of birth, year of completing education.
He is aware of the correct responses.

Intelligence:
Arithmetic- 79-42, 35/5, 34+67+90,23*12 he answered correctly.
Comprehension- what will you do when you find that you will be late by the
time you have reached your work spot- he responded .(I work overtime to finish
my work) -appropriate
Vocabulary- Aero plane ( Travel to other place), Bed (Sleeping), Breakfast
(Morning food) Book (Reading) -Satisfactory
26

General Information
•Prime minister of India, Chief minister of Telangana state, origin of corona virus
disease-
•He gave right answers.(Narendra Modi, KCR, China-Vuhan) ,
• Major cities in India (Bangalore, Bombay, Chennai, Hyderabad)
•Rivers (Ganga, Godavari, Krishna)
•Few countries (US, Canada, Britan)
•Capital city of India(Delhi)
Comment :Satisfactory
27

Abstract thinking:
 Proverb- Slow and steady wins the race and A barking dog never bites. He
answered I had never heard anything like it.
 Similarities and differences- He answered appropriately to differences
between cinema and radio (visual and non visual, ) stone and potato(stone is
for constriction potato for eating).
 Similarities: Mango and banana (Both color yellow) cow and horse (both
animals) Knife and Spoon (Kitchen item)
Based on these response his abstract thinking is at concrete level.
28

Judgement:
 Personal- He answered about his future plans- "I will go for a good position
and I will take care of my family members.“ It is Intact
 Social- His behavior during the session was found to be appropriate to
circumstances. It is Intact.
 Test- He answered about what he will do when he sees a stamped and sealed
envelope with an address.
He said I will post it in a letter box. It is Intact.
29

 Perception: No perceptual disturbances in any sensory modality could be
elicited.
 Thought:
a. Thought stream was intact , thought content and possession were clear of
any abnormalities , No Formal thought disorder.
 Mood: Subjectively, he reported to be ‘ok’ and objectively observed to be
anxious.
 Insight: Grade V ( Intellectual Insight).
30

DIAGNOSTIC FORMULATION
 The index client, Mr. YS, is 33 years old, Muslim, male, educated up to CS
and LLB, currently working as a corporate advocate in a private
organization, unmarried, belonging to a middle socio-economic status,
hailing from an urban background. He came with the chief complaints of
anxiety, feelings of guilt, hopelessness, sadness, social isolation, impaired
sleep, low appetite, lack of concentration, and thoughts of suicide (one
attempt). for 4 months.
31

32
The client's symptoms had an onset that was insidious, continuous, and
deteriorating. The significant precipitating factor is the breakup of his
engagement.
The MSE revealed that the client was well kept and appropriately dressed
upon arrival at the clinic. During the interview, he maintained eye contact.
The rapport could be easily established. His speech was coherent, his
productivity was normal and goal-directed. His reaction time was normal, and
his manner was relaxed.

33
His mood and affect were incongruent. He reported feeling okay, whereas his
ability was restricted. He was oriented to time, place, and people. His
attention could be aroused easily. His memory was intact. His abstract
thinking was conceptual.

TESTS ADMINISTERED AND THE RATIONALE FOR THE
TEST
1. Depression, Anxiety, Stress Scale (DASS-42)
DASS-42 was administered to assess severity level of Depression, Stress and
Anxiety of the patient.
2. Beck depression Inventory (BDI-II)
BDI-II was administered to assess the current severity level of Depression of the
patient.
34

Conti….
3. Suicide risk Assessment
Suicide risk Assessment was administered to assess the suicidal thoughts
35

TEST FINDINGS
1. On Depression Anxiety Stress Scale, the scores on Depression, Anxiety and
Stress scales were 23, 17 and 28 respectively. This indicates Severe levels of
Depression, Anxiety and Stress in the patient.
2. On Beck Depression Inventory, the total score was 45 indicating severe level
of depression.
3. On Suicide Risk Assessment, the total score was 11 indicating Low to
medium level of Suicide risk in the patient.
36

IMPRESSION:
(F32.) Severe depression episode without psychotic symptoms
37

Therapeutic Assessment
39
 Behavioral Analysis
Initial analysis of the problem situation
Behavioral excess
Feeling of Sadness
Increased feeling of anxiety

40
Behavioral deficits
Disturbed sleep
Disturbed appetite
Unable to focus on work
Social Isolation
Lack of Social communication
Crying

41
Behavioral assets
The client is aware that he needs to change.
Willingness to coming for Psychotherapy.

Motivational Analysis
42
 The client is showing his interest in coming for therapy session.
 He desired to be in a normal position, wanted to have good sleep,
appetite and feel more happy.
 He desired to concentrate on his profession.

Development Analysis
43
 Biological changes
Decreased sleep and appetite
Physically weak and tired
 Behavioral changes
Loss of interest on daily work
Unable to focus on profession
Worrying about future
Crying
 Psychological changes
Feeling guilty and sad
Decreased concentration

Analysis of self control
44
 The client was anxious about his future.
 Is my present engagement girl suitable or is another girl suitable for
me? He is confused.

Psychotherapeutic formulation
45
 The index client, Mr. YS, is 33 years old, Muslim, male, educated up to CS and LLB,
currently working as a corporate advocate in a private organization, unmarried,
belonging to a middle socio-economic status, hailing from an urban background. He
came with the chief complaints of anxiety, feelings of guilt, hopelessness, sadness,
social isolation, impaired sleep, low appetite, lack of concentration, and thoughts of
suicide (one attempt). for 4 months.
 The client's symptoms had an onset that was insidious, continuous, and deteriorating.
The significant precipitating factor is the breakup of his engagement.

46
 MSE revealed that psychomotor activity was appropriate. He was oriented to time, place
and self. His speech was relevant and coherent, pitch was normal reaction time normal
speed also normal ease of speech spontaneous relevance is relevant. Abstract thinking
was Concrete. Judgment is Intact. Memory is Intact and Intelligence was average.
Thought stream is normal Thought content is anxiety and fear. Test result Indicating that
the client have severe anxiety and depression.

Management - Goals
9/25/2022
47
Immediate
Goals
• To build
therapeutic
alliance (Done)
• Psycho-
education
about the
illness (Done)
Short term
Goals
• To lower the
levels of using
Relaxation
techniques for
anxiety
• To Improve
sleep quality
using Sleep
Hygiene
Activity
Long term
Goals
• To target the
fear and
depression
using CBT

Therapeutic Package
48
 Psycho education to the family
 Cognitive behavior therapy
A brief mood check
Activity scheduling
problem solving
Sleep Hygiene
A discussion of agenda items

Rational for Therapeutic Technique used
49
 CBT was used to help the client in recognizing and modifying his appraisals, and
faulty thought process.
 CBT Techniques are Cognitive restructuring, Thought record, Behavioral
activation.
 CBT aims to stop negative cycles such as these by breaking down things that
make us feel bad, anxious or scared. By making our problems more manageable,
CBT can help us change the negative thought patterns and improve the way we
feel.

Session-1. Building Therapeutic Alliances
50
 Session details
The client was seen twice in a week
The client expectations from the therapy was addressed and the goals of
therapy were made in collaboration with the therapist and the client.
Improvement in functional level, providing information through psycho
education and changing the thinking pattern.

Session-2. Psycho education
51
Session details:
 Psycho education to the client and family
 The therapy started with psycho education to the client and family regarding the nature,
course and prognosis of the illness.
 To Educate client about depression, the cognitive model (including the cognitive triad)
and about the process of therapy.
 To Gather information about client’s difficulties.
• To Discuss (and correct, if necessary) client’s expectations for therapy.

Session-3
52
Cognitive Behavior Therapy
Agenda:
 A brief mood check
 To Gather information about client’s difficulties.
• To Discuss (and correct, if necessary) client’s expectations for therapy

53
 Outline:
 Agenda will be set.
 Mood check will be done, including objective scores.
 Client’s presenting problem will be discussed.
 Client will be educated about cognitive model of anxiety and depression.
 Main Problems will be identified, and goals for treatment are set.
 Initial Homework will be assigned.

54
 Techniques:
 Problem-oriented focus initiation by developing goal list.
 Introduction of homework and reinforce value of self-help.
 Introduction of concept of automatic thoughts

Session-4
55
 Agenda:
 A bridge from the previous session its purpose is to help patients remember what was
important in the previous session and it helps that therapist and the patient .
 To Demonstrate understanding of basic cognitive model.
 To Identify automatic thoughts.
 To Use basic cognitive model to help learn coping skills.
 To Initiate testing of automatic thoughts.

56
 Outline:
 Focus will be on cognitive behavioral interventions appropriate to phase of therapy and
readiness of client.
 Home work will be assigned.
Interventions:
 Socratic questioning to prompt automatic thoughts.
 Testing of automatic thoughts.
 Introduction of thought recording.

Session-5
57
 The setting of an agenda
 To Promote collaboration in therapeutic relationship.
 To teach methods of changing automatic thoughts and apply to specific
situation.
 To Recognize cognitive errors.
 To Use thought recording to change dysfunctional cognitions.
 To Promote acting on a specific problem.

58
Outline
 Brief update will be obtained and mood check will be done.
 Agenda will be set collaboratively.
 Homework will be reviewed.
 Agenda will be discussed, and periodic summaries will be provided.
 New Homework will be assigned.

59
Interventions
 Socratic questioning (to prompt and test automatic thoughts)
 Challenging Cognitive errors.
 Thought recording procedures (typically a five-column thought record).
Homework:
 Reading assignment or worksheet on cognitive errors
 Thought recording exercise (typically a five- column thought record)
 Behavioral activation, brief problem-solving exercise or both

Session-6 and 7
60
Goals
 To Solidify client’s ability to use cognitive techniques to change automatic thoughts.
 To Help client learn to use behavioral methods to increase mastery and pleasure.
Outline
Same as that of previous sessions (Session 4 and 5)

61
Interventions/Techniques
 Socratic questioning and thought recording (and other cognitive procedures) to focus on a specific
problem(s).
 Understanding of automatic thoughts and cognitive errors with exercise performed in session or by
reviewing homework.
 Introduction of activity scheduling or other major behavioral intervention suitable for client’s problems.
Suggested homework
 Thought recording and related procedures
 Activity schedule with mastery and pleasure recordings
 Customized assignment.

Session 8and9
62
Goals
 To Solidify client’s ability to use cognitive techniques to change automatic thoughts.
 To Employ behavioral methods to effect change.
 To Review and update client’s goal list.
Outline
 Review and refine goal list.
Note: Same as the previous sessions (Session 4, 5, 6, 7)

63
Interventions
 Socratic questioning and thought recording (or other cognitive procedures) to focus on specific problem(s).
 Activity schedule for behavioral change or alternative behavioral procedure.
 Graded task assignments(GTA) if applicable or follow-up on GTA if used in previous session.
 Problem solving.
Homework:
 Thought recording
 Customized assignment
 Graded task assignment or other behavioral exercise, if applicable

Session10and 11
64
Goals
 To Solidify client’s ability to use cognitive and behavioral change technique.
 To Recognize underlying schemas (attitudes, beliefs, assumptions).
Outline
 Same as that of previous 3 sessions

65
Intervention
 Socratic questioning, thought recording
 Follow up on graded task assignment or other behavioral intervention (if used in
previous session)
 Psycho educational procedures or Socratic questioning to teach client concept of
underlying schema or identify and examine schemas if previously introduced.
 Practice problem solving

Session12 and 13
66
Goals:
 To Utilize schema change procedures.
 To Solidify client’s ability to use cognitive and behavioral change techniques.

67
 Interventions
 Socratic questioning, thought recording (and other cognitive procedures) to
focus on specific problems.
 Identify and examine schemas.
Note: All clients should have a basic introduction to schemas by Session 14 at
the latest.

68
Homework
 Schema list review
 Examining evidence or listing advantages and disadvantages of schemas
 Alternatives to dysfunctional schemas

Session 14 1nd15
69
Goals:
 To Fully implement schema change procedures.
 To Introduce relapse prevention techniques.
Interventions
 Socratic questioning, thought recording (and other cognitive procedures) to focus on specific problem(s).
 Identify and examine schemas; listing alternative schemas and developing assignments to practice new
schemas.
 Cognitive behavioral rehearsal or other CBT procedures to help client spot and manage potential triggers
for relapse.

70
Homework
 Schema change assignments as in sessions 12 and 13
 CBT rehearsal in vivo
 Problem solving

Session 16 and 17
71
Goals
 To Solidify gains from treatment.
 To Reduce risk of relapses.
 To Encourage continued use of self-help.
 Family bonding
 To improve social interaction
 To Set goals for future

72
Outline
 Obtain brief update and mood check.
 Fashion bridge from previous session.
 Collaboratively set agenda.
 Review homework.
 Discuss agenda items, and provide periodic summaries.
 Review methods of changing automatic thoughts, behavioral techniques and methods of changing schemas.
 Develop methods for managing triggers for relapse (use cognitive behavioral rehearsal if indicated).
 Set goals for future.
 Provide final summary, and get feedback.

73
Interventions
 Review of course of therapy; check for understanding of basic CBT concepts and procedures.
 Reinforce importance of continued use of CBT self-help techniques.
 Develop customized plan for using CBT to help reduce risk of relapse or reach future goals.
 Assist client with examining alternatives for further treatment or access to community resources if
indicated.
Homework
 Regular therapy folder review
 Thought recording and other CBT procedures
 Practice problem solving.

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