Summary

The client S.M was 48 years old divorced woman, educated till matric and 1st born among

4 siblings. She was initially seen by the consultant psychiatrist and then referred to the trainee

clinical psychologist at Centre for Clinical Psychology for the psychological assessment and

management of her symptoms of fear of enclosed washroom, palpitations, sweating, headache,

hopelessness, sadness, crying spells, constant fatigue, lack of interest in daily activities and

negative thoughts about future. She was assessed on formal as well as informal level. Informal

assessment was done with the help of Clinical Interview, Mental State Examination, Subjective

ratings of symptoms, DSM V Checklist and Dysfunctional thought record (DTR). Formal

assessment was done by using Beck Depression Inventory (BDI-II).The client was diagnosed

with Major Depressive Disorder. Therapeutic techniques which were used were

Psychoeducation, engagement of the client in therapy, Deep breathing, Progressive Muscle

Relaxation, Activity Scheduling, Pleasant activity sheet, Identification of negative thoughts,

Double column technique and graded task assignments. 9 sessions were conducted with the

client and post treatment revealed significant improvement in the severity of symptoms and level

of functioning.
Bio Data

Name S.M

Age 48 years

Gender Female

Qualification Matric

No. of siblings 4

Birth order 1st

Marital status Divorced

No. of children 4

Religion Islam

Informant Client herself and her daughter

Reason and Source of Referral

The client came to Centre for Clinical Psychology, with the complaints of of fear of

enclosed washroom, palpitations, sweating, headache, hopelessness, sadness, crying spells,

constant fatigue, lack of interest in daily activities and negative thoughts about future. She was

referred to the trainee clinical psychologist for the assessment and management of her problem.
Presenting Complaints

According to the client,

‫مجھے واشروم میں گھٹن محسوس ہونے لگ جاتی ہے اگر زیادہ دیر لگ جاُے تو‬

‫میں واشروم کا دروازہ بند کر کہ نہیں بیٹھ سکتی ایسا لگتا ہے میرا دم گھٹ جاے گا‬

‫سر نیچے کروں تو دل کی دھڑکن تیز ہو جاتی ہے‬

‫زیادہ تر اداس رہتی ہوں‬

‫ سال سے‬٩ ‫خوشی کی کوُی لہر محسوس نہیں ہوتی‬

‫جسم تھکا تھکا رہتا ہے‬

‫دل کرتا ہے ہر وقت روتی رہوں‬

‫زندگی سے بہت مایوس ہوں‬

History of Present Illness

The history of present illness of the client dates back when the husband of the client did

second marriage and gave divorce to the client. She was kicked out of the house by her husband.

He kept his sons with him and gave daughter to the client. The client came to his mother’s house

and started living with his brother. Few days after coming to her brother’s house, the client

started fearing in enclosed washroom. She had palpitations and sweating whenever she closed

the door of the washroom.This fear got intensified day by day.

‫میں واشروم میں زیادہ دیر بیٹھ نہیں سکتی گھٹن محسوس ہونے لگ جاتی ہے‬
 On the other the client started having body pains and reported that she suffered from

fatigue almost every time. Gradually she lost interest in the activities of daily routine and used to

spend most of the time alone in the room. She reported that nothing made her happy. She started

missing meals because of loss of appetite. Her sleep also became disturbed as she reported that

she couldn’t sleep normally. She had feelings of hopelessness and had negative thoughts like:

‫میرے ساتھ کبھی کچھ اچھا نہیں ہو سکتا‬

‫میرا مستقبل تاریک ہے‬

She had crying spells and reported that she used to cry on silly things and remained in

that state for hours. She remained sad and nothing brought her happiness as she was worried

about her and her daughter’s future.

In 2011, she consulted a renowned psychiatrist who prescribed her anti anxiolytics. She

remained on that medication for 3 years. But there was no improvement in her symptoms except

she was able to sleep properly with help of those medicines. In 2014, she consulted a

psychiatrist at Services hospital who prescribed her same medicine and advised her to get

admitted in the hospital. But the client was not willing to get admitted in the hospital so she

continued having medicine and stopped going to hospital.

From 2016, she was consulting a psychiatrist and was still on medication. She reported

that with the help of this medication she is just able to sleep properly and no other symptom is

improving. So one of her uncle suggested her to visit Centre for Clinical Psychology where she

was referred to trainee clinical psychologist for the assessment and management of her problem.
Background Information

Family History

The father of the client died at the age of 60 years. He was educated till matric and ran a

shop. The client was very attached to her father. He had cool temperament and used to get angry

occasionally. She was very close to him as she was his first daughter. she reported that the death

of his father was a great loss for her.

The mother of the client died after her divorce at the age of 75 years. She was

uneducated and the client had satisfactory relationship with her. She used to share her issues with

her mother before and after her marriage.

The client is eldest among all the siblings. The second and third born are sisters who are

married and lived out of station. The client has congenial relationships with her sisters as they

help her financially and also gifts clothes to her and her daughter. Fourth born is a brother who is

educated till intermediate and now works in a clock making factory. The client and her daughter

live with this brother. He is married and has three daughters. The client is very attached to him

and he also takes care of her needs. The last born is a brother who is physically disabled and

lives at home. The client has satisfactory relationship with him.

History of Psychiatric Illness in the Family

No history of psychiatric illness in the family was reported.

Personal History

The client reported that her mother told her that she was born through normal delivery at

home. She achieved all her milestones at appropriate level of age. She got extra care from her

father as he loved her a lot. The client had a friendly, jolly nature and temperament. She used to

get angry only occasionally. The client also reported that she was talkative by nature. She was
fond of doing household chores. She was interested in cooking and used to keep herself busy.

There was no reported history of serious physical injury, illness or trauma. No neurotic traits

were observed or reported by the client.

Educational History

The client started going to school at the age of 6 years. She reported that her school was

near her home and she completed her studies till matric from that school. She reported that she

was not much interested in studies but was studying as his father wanted her to do matric. She

was an average student and had congenial relationship with her teachers and fellows. After

matric she remained at home and started helping her mother in household chores.

Sexual History

The client reached puberty at the age of 14 years. She was not aware of that significant

change in her body. Her mother guided her regarding the ways to handle her menstrual time

period. She adjusted herself in that major transition and faced no difficulty in accepting it. She

had no sexual relationship before her marriage. The client had no homosexual inclination. No

sexual or physical abuse was reported during her childhood. The client had her first sexual

relation with her husband.

Marital History

The husband of the client ran a clinic and gave medicines to people. The client reported

that she had satisfactory relationship with her husband only for 1 year. He started abusing her

physical and verbally right after the birth of her daughter. She reported that she was very

beautiful at the time of her marriage so her husband took care of her and loved her. With the

passage of time, as her beauty declined, he started losing his interest in her and used to fight with

her all the time. Initially they had normal sexual life that she found mildly pleasurable but due to
continuous fights with her husband, the client could not maintain regular sexual relation with her

husband. After 15 years of marriage the husband of the client married again and kicked her out

of his house. She had 4 children. The eldest child was a daughter of 22 years who had dome

intermediate and was now giving tuitions to children. She lived with her mother. She has

congenial relationship with her mother. The 2nd born son has done matric and was helping his

father at clinic, the third born is also a son who is not educated and is free nowadays. The last

born has recently done matric and is willing to continue his studies. The sons are not allowed by

the father to meet their mother but they often come to meet her. Client has congenial

relationships with her sons.

Premorbid Personality

The patient’s personality was reported to be pleasant and cheerful before her illness. She

was friendly, outspoken and she spent her leisure time in useful activities like cooking or

laundry. Her predominant mood was cheerful. She also had friendly relationships with her

siblings and had appropriate relationships with her family. She was sensitive and was vulnerable

to stress but she reported that she was able to cope with her stress effectively. She was good in

maintaining relationships. She was religious throughout her life and reported that she became

more close to her religion after the death of her father. She had a compromising nature and was

able to adjust in every situation.

Psychological Assessment

Psychological assessment of the client was carried out to get the information regarding

the nature of her symptoms, causes and maintaining factors for diagnosis and managing them.

The assessment was done at two levels.

 Formal Assessment
  Informal assessment

Informal assessment

The following measures were used for this purpose:

 Clinical Interview

 Mental State Examination

 Subjective ratings of symptoms

 DSM V Checklist

 Dysfunctional thought record (DTR)

Clinical Interview

A detailed clinical interview was conducted with the client and her daughter to get

thorough and detailed information about her present illness, presenting complaints, identifying

data, family history, educational history, background information and personal history as well as

premorbid personality. It was also done to probe every possible factor which led to the problem

and also the factors which were maintaining the illness. Moreover, it provided detailed

information about the history of present illness and previous treatment. This information was

used to devise an idiosyncratic case formulation and management plan for the client.

Mental State Examination

Mental State examination was conducted in first session to analyze the current

functioning level on cognitive and behavioral level of the client. The client had bloomy

expressions. She had an average height. She was wearing dress of dull color. She was sitting on

the chair bent towards the therapist. She maintained eye contact for some time and used to look

down most of the time. Her speed of speech was slow and tone was low. She was cooperative

towards the therapist and showed compliance. She was motivated to deal with her symptoms.
Her mood was low. There was no evidence of hallucinations and delusions. There was no

evidence of obsessions and compulsions or suicidal ideation. She had insight about the

psychological nature of her problem. She was well oriented in time, place and person. She was

motivated enough to seek the treatment. Her general knowledge and abstract thinking was

adequate. Her generalization and conceptualization were adequate.

Visual Analogue

The severity of the presenting complaints was assessed on 0-10 point scale. The client

was asked to rate her presenting complaints from 0-10 to get an estimate of the intensity of

symptoms at pretreatment stage. In the given scale, 0 indicated no problem at all, while 5

indicated moderate and 10 indicated severe problem.

Table 1

Pre-Treatment Subjective Ratings of Presenting Complaints By The Client On 0-10 Point Scale

Symptoms Pre- treatment Ratings

Sadness 10

Loss of Interest 10

Loss of pleasure in daily activities 9

Feelings of hopelessness 9

Fatigue 8

Crying spells 9

Fear of enclosed washroom 9

Dysfunctional Thought Record (DTR)

 The dysfunctional thought record was given to the client to identify the predisposing,

precipitating factors, negative automatic thoughts, intensity of the beliefs on NAT’S and coping

strategies adopted by the client to deal with the NAT’S.

Table 2

Qualitative Analysis of Dysfunctional Thought Record

Areas Content

Precipitating Factors Second marriage of husband, Divorce from

husband

Negative Automatic Thoughts I am hopeless about future, I can never be

happy

Feelings Sadness, feelings of hopelessness

Coping Strategies Sitting alone and focusing on past

Formal Assessment

Beck depression Inventory and Beck Anxiety Inventory were administered as formal assessment

to measure the severity of depression.

Quantitative Analysis of Beck Depression Inventory

Table 3

Raw score, Cutoff and corresponding Remarks of BDI at pre-treatment level

Raw Score Cutoff Remarks

44 30-63 Severe
 The client obtained a score of 44 on Beck Depression Inventory (BDI) which falls in the

category of severe depression. It shows that the client had severe level of depressive symptoms.

Quantitative Analysis of Beck Anxiety Inventory

Table 4

Raw score, Cutoff and corresponding Remarks of BAI at pre-treatment level

Raw Score Cutoff Remarks

27 17-29 Moderate

The client obtained a score of 27 on Beck Anxiety Inventory (BAI) which falls in the

category of moderate anxiety. It shows that the client had moderatelevel of anxiety symptoms.

Diagnosis

296.23 (F32.2) Major Depressive Disorder, single episode, severe

300.92 (F40.248) Specific Phobia, situational

Case Formulation

According to DSM-5, a person having depressed mood, sadness, loss of interest in

pleasurable activities, loss of appetite and sleep, psychomotor agitation, feelings of helplessness

and hopelessness, recurrent thoughts of death and significant distress in social and occupational

functioning since last two weeks is diagnosed as major depressive disorder. The above

mentioned symptoms related to the case of client became the reason of diagnosis of Major
Depressive Disorder. The client was also fearful of enclosed washroom and she started having

symptoms like sweating and palpitations there. She also fulfilled the criteria of specific phoba so

she was also diagnosed with Specific Phobia.

Beck (2002) believed that depression is consequence of negative triad i.e.;

negative thinking pattern of self, others and the world. People who interpret their future and

experiences as negative way make certain thinking errors which become the reason for

persistence of depression (as cited in Comer’s 2000). In the present case, client also had negative

triad. She had negative view about herself; I am worthless as I have failed my marriage. She also

had negative view about her future; I have not hopeful regarding my future as I will never be

happy and my future is dark.

Client found herself inadequate and helpless in her life as she thought everything is out of

her control this is consistent with attribution-helplessness theory, when people view events as

beyond their control, they ask themselves why this is so (Taube-Schiff & Lau, 2008; Abramson

et al., 2002). If they attribute their present lack of control to some internal cause that is both

global and stable (“I am inadequate at everything and I always will be”), they may well feel

helpless to prevent future negative outcomes and they may experience depression.

According to Seligman (1975) as cited in Comer’s 2012, such feelings of helplessness are

at the center of her depression. Seligman has developed the learned helplessness theory of

depression. It holds that people become depressed when they think (1) that they no longer have

control over the reinforcements (the rewards and punishments) in their lives and (2) that they

themselves are responsible for this helpless state. So, it is consistent with the background history

of patient as she had learned that she is unable to control her situation and became helpless

infront of her husband.

 Beck (2002) claimed that depressed people hold maladaptive attitudes and that the more

of these maladaptive attitudes they hold, the more depressed they tend to be (Evans et al., 2005).

Depressed individuals seem to recall unpleasant experiences more readily than positive ones, rate

their performances on laboratory tasks lower than non depressed people do, and select

pessimistic statements in storytelling tests, this is consistent with the case of this patient’s belief

that as he reported (“I expect I never can do anything good”, I can’t expressed my feelings, no

one have concern with me). Depressed people experience automatic thoughts, a steady train of

unpleasant thoughts that keep suggesting to them that they are inadequate and that their situation

is hopeless. As patient reported that “I’m worthless . . . I’ll never amount to anything. . . .

Everyone hates me. . . I’ve failed as a person... Everything is difficult for me” (Mendels, 1970)

as cited in Burn (1980). In the present case they client only focused on the negative things in her

life.

Watson's (1919) has viewed specific phobia as resulting from a learned association of a

negative consequence paired with a neutral stimulus. According to Mowrer two factor model of

phobia (1960), the initial fear was established through classical conditioning (e.g., the neutral

stimulus of the symptoms presence in washroom was paired with the negative experience of

being suffocated, breathlessness and palpitation). However, avoidance of the close spaces in the

future was based on operant conditioning that is, when the patient approached an enclosed

washroom there was an increased fear. Avoiding or escaping was associated with reduction of

fear (thereby negatively reinforcing the operant of escape or avoidance through the consequence

of fear reduction). The two-factor model thus accounted for the acquisition of fear through

classical conditioning and the avoidance of feared stimuli through the negative reinforcement of

reducing fear through the operant of escape of avoidance. Fear was thereby conserved.
 Watson and Rayner (1920) originally argued that phobias are simply intense classically

conditioned fears that develop when a neutral stimulus is paired with a traumatic event, such as

in this case intense fear of close and confined spaces paired with washroom. As she was in

washroom when she felt palpitation, breathlessness and anxiety, she associated them with

washroom. It can be confirmed that many people with phobias can recall a traumatic

conditioning event when their phobia began (O¨st & Hugdahl, 1981)
Idiosyncratic Case Conceptualization

Early Experiences

Divorce

Formation of Dysfunctional Assumption

I will not be able to make successful relationship

Assumptions Activated

I am hopeless about future

Negative Automatic Thought

My future is dark

Every bad thing happens to me

Symptoms of Depression

Affective: Sadness, low mood

Somatic: Headache

Behavioral: Crying spells, low activity level, staying in her room

for hours

Motivational: lack of pleasure and interest in routine activities.

Cognitive: Low self-esteem, worthlessness, hopelessness

Idiosyncratic model of Phobia

Trigger

Going to washroom

Perceived Threat

‫مجھے کچھ ہو جاے گا‬

‫میرا دم گھت جاے گا‬

Anxiety

Misinterpretation of Physical and cognitive

symptoms symptoms
‫میں مر جاوں گی‬ ‫دل کی دھڑکن تیز ہو جانا‬
‫مجھے دل کا دورہ پڑ جاے گا‬ ‫سانس بند ہونا اور پسینے آنا‬
Management Plan

The management plan was devised on the basis of Cognitive Behavioral Therapy

Short Term Goals Therapeutic Intervention

Engagement of the client in therapy and

building a therapeutic alliance and to enhance  Rapport Building

good rapport building

To provide the client information regarding her

 Psycho-education
problems.

Identification and understanding depression  Socialization

Understanding her fear  Normalization

 Case conceptualization

 Explanation of panic model

To improve and return to the normal previous  Pleasant Activity Sheet

functional level of the client and to reduce the  Deep breathing

lethargy through behavioral strategies  Progressive Muscle Relaxation

 Explanation of Lethargy Cycle

Identification of NAT’s and source behind  Daily thought Record (DTR)

depression.  Verbal Challenging

Replacing NAT’s  Double column

 Cost Benefit Analysis

To induce sense of gratitude in the client  List of gratitude

To deal with her phobic thoughts in washroom  Coping statements

Repeatedly face fears and come into contact  Behavioral experiment

with progressively stronger fear-inducing

stimuli until habituation is reached

Long term Goals

 To attain the client’s previous level of functioning by improving her mood.

 To enable the client to deal with the symptoms effectively.

 To alter the client’s negative beliefs and views regarding her and world.

Summary of Therapeutic Intervention

Rapport Building

Rapport was build with client by asking her favorite activities etc. Therapist initiated

rapport by introducing herself, by active listening and showing empathy toward her issues.

Trustworthy relationship with client and was billed by therapist and confidentiality was assured

to client.

Clinical interview was also conducted with client in order to probe the history of present

illness and stressors of the client. Therapist took the subjective ratings of presenting problem.

This ranged from 0-10 point severity rating scale. The purpose of this rating was explained to

client that this will be helpful for therapist to devise appropriate management plan and to assess

its effectiveness.

Rapport was easily built with the therapist as she started explaining her issues to the

therapist
Psycho education

The client was psycho-educated regarding her problem. Cognitive model of depression

was used to inform her how her symptoms were persisting by explaining the vicious cycle to her.

The client was also informed about possible causal factors and other factors which played an

important role in the maintenance of her depressive symptoms and phobia. Psychoeducation was

further broadened by informing her about the details of the therapeutic process and the time of

each session. She was educated about automatic thoughts and negative automatic thoughts

through ABC model. She was educated that NATs were a part of her depressive state and led her

to believe that these negative thoughts resulted in impaired functioning. Model of CBT was also

explained to the client. Panic cycle was introduced to make her understand her fear and reason

why she started having bodily symptoms. She was also informed regarding the possible ways to

get the treatment along with the affectivity of treatment. The client reported to have clear

understanding of her problem.

Daily Thought Record (DTR)

Daily thought record was given to the client to get the details about her negative

automatic thoughts and fear. The chart was given to the client and she was asked to fill it

according to her thoughts. After getting the filled chart the negative automatic thoughts (NAT’s)

and her fear of washroom were identified which were catered then in the upcoming sessions.

(See Appendix C:

Verbal Challenging

In the present case reattribution training was done to help the client in identifying her

maladaptive attributions i.e. whatever happened to the client attributed it totally to herself which
depicted that client had internal attribution style of negative events occurring in her life. In this,

the client was asked to tell the last event and the attribution to that event was discussed. The

client was then explained the link between attribution given to the event and the associated

feelings i.e. sadness, worthlessness and hopelessness. It helped in understanding the role of

negative automatic thoughts and their consequences.

The client was also challenged regarding her fear using ‘What…If’ questioning. She was

guided about her maladaptive thoughts that activated her bodily symptoms in washroom. Panic

cycle was also explained to the client to make her understand what are the reasons that hold her

fear in enclosed washroom. She understood the cycle and related it with herself .

Relaxation Exercises

The client was taught Progressive Muscle Relaxation and Deep Breathing to alleviate and

manage her physiological and somatic symptoms. She was given the instructions in written form

and was asked to practice them twice a day. Moreover it also helped in teaching her the

discrimination in relaxed and tensed states. She was asked to practice this exercise in her daily

routine to keep herself relax and calm. The client reported that her headaches and general body

pains were considerably reduced.

Pleasant Activity Sheet

In order to alleviate the physiological symptoms of depression, techniques like pleasant

activity sheet and PMR were used. It was done with the client, in which the client was asked to

follow the tasks and routine devised in the session with the help of the client and the therapist.

She was asked to rate her mood on a 100 point scale before and after performing the given task.

She was also given the importance and role of this activity in the therapy and the management of
her symptoms. Through this technique, the client was inclined to presume a normal daily routine

and less time was spent in negative thoughts and helplessness. The schedule gave the client a

sense of direction and self-control. It was kept under consideration to enable client to seek

pleasure from her favorite activities which were being ignored by her due to her symptoms

negative experiences. A written chart was given to the client initially to rate her mood before and

after each activity performed. Later, the charts were withdrawn and the client began to mentally

rate the mastery and pleasure to enable her to automatically do so. (See Appendix C: )

Lethargy Cycle

Lethargy cycle was explained to the client to make her able to understand the vicious

cycle of depression and its role in lethargy. She understood the cycle and decided to break it by

her inner motivation. She was guided regarding controlling of the factors which led towards the

lethargy in daily routine. (See Appendix C: )

Double Column

The client was educated regarding the logical errors to help her identify her own faulty

logics. She was given examples of her daily life. The technique was used to identify the

maladaptive thoughts. In the next session, when the client had identified her illogical thinking,

she was helped to generate rational responses and was given it as homework to practice at home.

The client was able to generate logical responses to negative thoughts that came to her mind.(See

Appendix C: )
To induce sense of gratitude in the client

She was guided to manage her grudges in healthy manner. She was asked to generate a

list of things she is grateful about in her life. A list of gratitude was maintained by asking the

client. It made her able to understand that she had many positive things and people in her life. It

induced a sense of gratitude in her.

Coping statements were also given to the clients to deal with her fear in washroom. The

coping statement were short statements like “I can control my fear”, “nothing will happen to me

if I think this way”, “I am powerful than my symptoms” written on the flash cards. The client

was asked to repeat them loudly whenever she felt anxious in the washroom. These statements

helped the client in dealing with her thoughts that used to disturb her in the washroom and lead

to palpitations and sweating. (See Appendix C: )

Behavioral Experiments

Initially the client was asked to imagine the situation she was fearful of in the session

room. The therapist dictated all the cues that made her fearful in the washroom but she couldn’t

experience the symptoms as she reported that she will not have the symptoms this way. Then the

daughter of the client was guided about how to perform behavioral experiment at home. She was

guided to close the door initially at 60 degree angle and stand outside the washroom. She was

guided to rate the anxiety every time she goes to washroom. When the anxiety was reduced she

was to guided to reduce the angle of closing the door at 30 degree and rate the anxiety. The

symptoms of anxiety, palpitations and sweating started reducing as she was asked to practice
coping statement during these experiments. These behavioral experiments and coping statements

helped her in reducing her fear of enclosed washroom.

Outcome of Therapy

Post assessment

Table 5

Pre- and Post-Treatment Subjective Ratings Of Presenting Complaints By The Client On 0-10

Point Scale

Symptoms Pre- treatment Ratings Post treatment ratings

Sadness 10 5

Loss of pleasure in daily activities 10 4

Loss of interest 9 5

Feelings of hopelessness 9 5

Fatigue 8 3

Crying spells 9 2

Fear of enclosed washroom 9 4

Comparison of Pre and Post Treatment Ratings of BDI- II

Table 6

Pre and post Raw score, Cutoff and corresponding Remarks of BDI at pre-treatment level

Pre-treatment Raw Pretreatment Post-treatment Raw Post-treatment

Score remarks score remarks
44 Severe 25 Moderate

The comparison of pre and post treatment revealed significant improvement in the level

of depression as it decreased from severe to moderate.

Comparison of Pre and Post Treatment Ratings of BAI

Table 7

Pre and post Raw score, Cutoff and corresponding Remarks of BAI at pre-treatment level

Pre-treatment Raw Pretreatment Post-treatment Raw Post-treatment

Score remarks score remarks

27 Moderate 14 Mild

The comparison of pre and post treatment revealed significant improvement in the level

of anxiety as it decreased from moderate to mild.

Graphical Representation of Pre and Post subjective ratings of Presenting Complaints

Graph 1

Pre and Post ratings of subjective ratings of presenting complaints

 12

10

4
Pre treatment ratings
Post treatment ratings
2

0
ss e t ss ue lls
ne ur es ne pe oo
m
d as ter
ss atig s r
Sa le in le F g sh
fp of pe yin wa
ss
o st Ho Cr d
Lo Lo se
clo
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ar
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Critical Evaluation

The client was 48 years old female who was diagnosed with Major Depressive Disorder

and Specific phobia. Therapeutic techniques which were used were Psychoeducation,

engagement of the client in therapy, Deep breathing, Progressive Muscle Relaxation, Pleasant

activity Sheet Identification of negative thoughts and Double column technique. All the

techniques proved to be very effective with the client as there was marked improvement in the

symptoms of the client. Behavioral experiment was also proved to be very effective.

Termination of the therapy

9 sessions were conducted with the client and post treatment revealed significant

improvement in the severity of symptoms and level of functioning. Follow up sessions were

suggested to be taken.
References