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Case 4 Akmal

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Case: 4

Methamphetamine used disorder

(F15.22)
Summary

Client "M A" was a 38 year old man. He was referred to me by the in charge of Young

nation. He was neat and clean. He was suffering from drug cravings or addiction. He started

smoking and chars 10 years ago. The reason for his behavior was stress and Craving. He was

cooperative and an extrovert. Clients also reported the present guilt of using drugs. The client

was ready to move towards positivity.


Identifying data:

Name: M A

Age: 38

Gender: Male

No of siblings: 8

Birth order: 3rd

Father: dead

Mother: Alive

Informant: client Himself

Source and reason of referral

The client as referred by in charge of Young Nation to me for talking a detail case history

on his sudden change in behavior and addiction.

Presenting complaints:
Presenting complaints reported by client.

Duration

Presenting Complaints

‫تھا وتا ڈیپریشن‬ ‫سال ایک‬

‫آٹھ ما‬ ‫تھا آتا بت غص‬

‫آٹھ ماہ‬ ‫تھی آتی نیں نیند‬

‫سال ایک‬ ‫تھا وتا محسوس‬

‫پن اکیال‬

Observational assessment:

Client was 38 years old. He entered in the session room with manners. He was showing

little irritating behavior. He was looking left and right because he feels anxious and nervous. He

was neat and clean.

History of present problems:

Client reported that his crave a lot because of addiction. He feels craving of drug almost

after 2 days. He use alcohol before 5 years, after taking of ICE he use ice regularly.

Personal History:
As reported by client he did not talk much. He is the shy person did not like to attend

the family functions. Client was the one of the source of income in his family. When the

disturbing periods start he becomes angry at everyone.

Family History:

He was born as 3rd child in his family. He lost his father because of heart attack. He was

very close to his father. His family suffers because of disturbing periods, because of he is the

source of income in his family after his father death. None of his family has any psychiatric or

physical illness.

Educational history:

Client was not interested in studies. He is the talented he reported. After middle he feels

no interest in study. So he skips his studies.

Quantitative interpretation:

Some score of all the items are:

Scoring

12-24: low craving

25-39: Moderate craving

40-59: High craving

60-84: Extreme high craving


His total score is 51 (Solve questionnaire is attach in appendix) according to his score he is

suffering from Methamphetamine craving.

Qualitative:

Case formulation

Presenting complaint

 Lack of income

 Day by day aggressive behavior

 Can’t talk too much

Personal factors:

 Father death

Family factors:

 Father death

 Relation with sibling

Assessment:

 Subjective rating

 Methamphetamine craving questionnaire

Management:
 Report building

 Deep breathing

 Rules of sleep

Counseling plan:

The plan was on the basis of anger and stress

Counseling sessions:

Session 1

Aim: Rapport Building and identifying problem

The client "A" came in. I greeted him and asked him to sit in a comfortable way. The

Client appearance: the client was well dressed, neat and clean. I decided to make sure that the

client is comfortable and told him he can Make him as easy as home. The session officially starts

with the history taking and mental examination. The client was showing some activities as he

wanted to go from the sessional room. So I Ended the Session after taking history.

Session 2

Aim: Administrating subjective rating scale.

Today the session starts with taking the further history of the client's addiction or

craving. Today he was more comfortable and talked easily. I did a subjective rating on him. He
scored 51 high cravings. He used smoking and ice unlimited for 4 years. He always craves after

taking drugs. I asked him what makes him angry whenever he thinks about his future.

Session 3

Aim: Religious copying statements and deep breathing for stress management.

The Session starts with the conversation on our religious Islam. I asked him to pray five

times in a day and recites Holy Quran daily in the morning. He said yes he will do it properly. He

shows some body movement as Leg Shaking and Movement. So I told him how he can make

himself relax. I told him Deep breathing exercises when he feels Anger or Stress.

Today's session was able to get the purpose with which it started.

Session 4

Aim: Psycho education on anger and stress management.

After listening to his family issues in the previous session, I concluded that these

tensions of Family make him aggressive and addicted to drugs. We discussed issues and

possible solutions and told him he can do everything for his family. I said that I understand his

problems if he could keep on worrying about it could lead to severe mental and health issues. If

he could keep himself busy he experience good sleep.

Today session was able to get the purpose with which it started.

Session 5
Aim: Discussion with clients in technique to avoid drugs.

Today's session starts with the conversations on what he can do to avoid Drugs. He said

he will not think about it and never try to buy it again. So, I told him to avoid these you have to

make good relations with your family and spend more time with them. It will make you think

that you don't want to hurt them again. Your family and children suffer again from it.

Session 6

Aim: saying goodbye to the client and taking post-assessment.

Today the client was showing more confidence and active behavior. I already prepared

him that one day we will say goodbye to each other. We also discuss that I will help him if he

needs. He walks out of the room with confidence and happily.

Sessional report:

Goal:

 Rapport building

 Teaching deep breathing

Islamic learning

Rationale:

 Rapport building: to make client comfortable

 Deep breathing: to control stress and anger

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