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Case 05

Substance Use Disorder

(F19.259)
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Summary

Client F.Q was 26 years old man. He was referred to me by the in charge of rehabilitation center.

He was neat, clean and well dressed. He was addicted to substance use disorder from 6 7 years.

He started smoking at the age of 19. Now he has been drinking ice for the past 5 or 6 months.

The reason for this behavior is his breakup. He was cooperative. He maintains good relationship

with members. Client also reported a present guilt feeling about all the bad things he had done.

Client was ready to move forward positivity after treatment ends.

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Identifying data:

Name: F.Q

Age: 26 years

Gender: Male

No.of Siblings: 04

Birth Order: 3rd

Father: Alive

Mother: Alive

Informant: Client himself

Source of referral

His family brought him to the rehabilitation center

Reason of referral

Client was referred by the in charge of rehabilitation center to me for taking a detailed case

history on substance use disorder. He was addicted to ice, charas,smoking,afeem (opium) and

alcohol with psychotic illness depression.

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Presenting Complaints
Duration Complaints

‫دو تین ماہ میں‬ ‫میرا سات کلو وزن کم ہوا‬

‫دو تین ماہ‬ ‫نیند نہیں آتی تھ ی‬

‫چھ سات ماہ‬ ‫غصہ آتا تھ ا‬

‫تین چا ر ماہ‬ ‫س ر درد رہتا تھا‬

‫پانچ ماہ سے‬ ‫بھوک محسوس نہیں ہوتی تھی‬

Observational Assessment

Client was 26 years old boy. He entered in session hall with confidence. The client’s

appearance was well dressed neat and clean. He was maintaining good eye contact.

History of present problem

Client reported that his condition got worse from last one year because of his addiction to
drugs.

Personal History

As reported by client, my father and brother used to drink, so I also started drinking. I

was influenced by them. He started drinking at the age of 16, 17. He has been using alcohol

along with smoking hashish and opium for about 6 to 7 years. After that, he went through a

breakup, and due to depression, he started using meth (ice) for the last 5 to 6 months. The

amount of ice increased day by day.

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Family History

He was born as 3rd child in family. His father works as a butcher. He is unmarried. Client

relationship with family is good.

Educational History

He is uneducated. No interest in study.

Previous and present physical illness:

There was no previous and present physical illness

Psychological Assessment

Formal and informal assessment was done with the client in order to access and to decide

a counseling plan for the client’s problem.

Formal Assessment

Psychological test

Beck Depression Inventory (BDI)

Score Degree of the problem related to drug’s

0_9 Minimal Depression

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10-18 Mild Depression

19_29 Moderate Depression

30_63 Severe Depression

Score: 31

Etiology:

The etiology of patient’s condition are psychosocial and psychoanalytical factors

Assessment

Subjective Rating

BDI

Counseling Session

Session 1

Aim: Rapport building and identifying problem

The client F.Q came in. I greeted him and asked him to please come in and take his seat.

The client’s appearance; the client was well-dressed, neat and clean. He was cooperative. I

decided to make sure that the client is comfortable and told him he can make himself at home

here and whatever he would tell me will be confidential. I am an intern working here and he can

feel free to convey whatever he wants. He hesitated for a second then he said he is addicted to a
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drug known as ice, chars, afeem(opium), smoking and alcohol. It was an introductory session in

which the general problems of client were asked and the objective of communication was

discussed with the client.

Today’s session was able to achieve the purpose with which it started.

Session 2

Aim: Taking information about premorbid personality

Today, he seemed much more comfortable. I asked him to tell me more about himself,

how his life was before his addiction, his social interest, social relationship, and any past present

physical problem. He maintains good relationship with members. He was physically fit before

addiction. , In this session client’s pervious & present illness were also discussed. There is no

any previous and present physical illness. He has a psychiatric illness that is depression from last

5 6 months.

In this session Mental Status Examination was also done. He was well mannered person.

Maintain distance with me. He was maintaining good eye contact. In this session he told me

about his suicidal thoughts and has tried to kill himself as he was suffered from major depressive

disorder. After using ice, he neither felt sleep nor hungry.

Today’s session was able to achieve the purpose with which it started.
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Session 3

Aim: Administrating BDI (Beck Depression Inventory) test

I told the client that I would ask some questions and that they should answer them to assess the

level of his depression. Client’s score on BDI is 31 that’s fall in severe depression. The client

responded very cooperatively, and the test was completed in this way

Session 4

Aim: Checking his memory, attention and concentration

Today’s in this session client’s orientation was good as he respond accurately when asked

about the place, year, date, month. His rate of speed was normal. Client attention and

concentration was not so good. He only knew the days of the week. He didn't know the names of

the months. He also didn't know the names of the days in the correct order. His memory intellect

and vocabulary were not good. He was not able to recall the event from in past easily.

Today’s session was able to achieve the purpose with which it started

Session 5

Aim: Goodbye to client.

Today was my last session with the client. Client was ready to move forward positivity

after treatments ends. After the session ended, I said goodbye and wished him a speedy recovery.