Case Summary

Miss M is a 22 year old female, doing her Master’s Degree and resides in
Islamabad. For the last two years she has been having occasional episodes of
anxiety attacks and also suffers from depressive mood and exam related anxiety.
She often experiences high levels of stress, overwhelming thoughts, mood swings
and pent up aggression alongside sleep disturbances and suicidal thoughts. The
patient has problems dealing with university life and socializing due to her
symptoms. Formal assessment was done by using Beck’s Depression Inventory
(BDI) and The State- Trait Anxiety Inventory (STAI).
 SESSION REPORT

Session-1
Date: 1stth Dec.2021

During the first session, the aim was the build a good therapist-client relationship.
We discussed the timings, length and location of our sessions. An informal
interview was conducted and gradually rapport was built. The interview was done
to attain background information about the client, their problems, lifestyle,
interpersonal relationship and other important details. The interview was
conducted in the garden of NUML University after off-time, hence there were not
many disturbances and the client reported to be comfortable.
During the first session Mental Status Examination was done. Initially the
client was a bit reserved about sharing information, seemingly hesitant and
anxious. She kept avoiding eye contact and fidgeted quite often. She appeared
nervous or worried and would constantly frown, even when she was not speaking. I
gave her a mood worksheet so she could express her emotions at the current
moment. After accessing her mood and understanding that most of her problems
revolve around anxiety and depressive mood symptoms, I decided to teach her
relaxation techniques, which included:
 Deep Breathing technique
 Progressive Muscle Relaxation technique
After client practiced these techniques and felt a bit relaxed, I gave her two
diagnostic questioners to fill out, so that I could assess the severity of any disorder
if present.
Client Response
At first the client didn’t take the idea of relaxation techniques seriously, saying
they were going to be “childish and a waste of time”. However she did seriously
follow my instructions and try the deep breathing exercise and felt an immediate
low intensity difference. According to the client her heartbeat had regulated to a
more comfortable pace and she felt less nervous attending the session. She herself
suggested that she wanted to learn the second technique aswell. She cooperatively
filled out the diagnostic tests and actively tried to focus on the session. Even her
body language had become for comfortable and less defensive.

Tests Administered
 The State- Trait Anxiety Inventory (STAI)
 Beck’s Depression Inventory (BDI)

Test Scores
The client scored 48 on State anxiety which indicates moderate anxiety and 53 on
Trait anxiety which indicates high overall anxiety.
The client scored 40 on BDI which indicates moderate depression.

Howework Assignment
 Practice relaxation techniques and note in journal when and why they
needed to use it
 Fill mood worksheet once everyday till next session
 Note down any thoughts or feelings they would like to discuss next time
(optional)
Session-2
Date: 7th Dec.2021

We began with a feedback of the previous session, The client reported to have felt
slightly better and less anxious as compared to how she used to feel before. She
still reported to have had two anxiety attacks over the past week, which she tried to
handle with relaxation techniques. She had tried to do the homework I had
assigned, not entirely however. 2 of her mood worksheets indicated that she had
suffered from intensely negative emotions recently.
During the second session we thoroughly discussed the issue of her fear of
exams and issues in her capacity for interpersonal relationships. I assessed her
responses and was able to comprehend the cognitive errors present in the client’s
thinking patterns. By following CBT techniques, I first educated the client about
what cognitive distortions are and how she uses them. I tried to change her
perceptions by making her reframe and redefine her problems. We discussed the
problems she is having in adjusting to her university life and I was able to narrow
down that my client is bad at social interactions. When questioned about it she
admitted that she is rather awkward and most of the time doesn’t know how to
react to social situations, especially those related to classmates and teachers. I
connect this information to my client’s introverted nature and avoidance of making
close friendships. Lastly, the reason of her recent anxiety attacks was explored
which was her overthinking social interactions between her university classmates
and university homework. With gentle confrontation I was able to bring all of these
factors into the client’s knowledge. We also performed fact-checking exercise so
that I could help the client understand that some aspects of her perspectives are
formed by opinions and not facts.
Following Skills were taught to the client during the session:
 Distress Tolerance
 Interpersonal Effectiveness
 Emotional Regulation
 Dysfunctional and Automated Thought recognition
 Fact checking
The client was taught how to asses a distressful situation and how to effectively
handle it without being emotionally whelmed. Whilst teaching the skills, we side
by side practiced relaxation techniques. I explained and taught the client how
improve their social skills by roleplaying and a sample exercise of Interpersonal
effectiveness skill. The client was taught how to recognize and logically react to
dysfunctional thoughts and automated thoughts.
Client Response
The client was cooperative and more open to the session than last time. She
seemed relaxed and wanted to participate in the exercises I was teaching. While
discussing the issue of her fear of exams, she admitted that it was mostly a fear of
academic evaluation. The client stated that she started becoming more anxious
related to her academics since she entered university as her parents have to pay
expensive fees and she felt a pressure to perform. She felt that she is always graded
unfairly as compared to other students in class. As for interpersonal relationships,
the client disclosed that a year ago she had an awful fallout with her closest friends
and became extremely introverted as a result. She has internalized the lack of need
for interpersonal relationships and being emotionally close to any individual. She
feels that it’s pointless to make new friends as they will follow the footsteps of her
old friends. When educated about dysfunctional thoughts and cognitive distortions,
the client was quick to notice and identify the ones she uses in her thought
processes related to the above topics. She identified them as:
 Overgeneralization
 Mental Filters
 Jumping to Conclusions
 Magnification
 Personalization and Blame
The client attentive followed the exercises that were taught, i.e. closing and
opening fist and forming mental images for distress tolerance etc. While
performing the ‘G.I.V.E’ exercise for interpersonal effectiveness, the client felt
that she should use this more often when interacting with her friends. During the
role-play session, the client effectively was able to let out her complaints that she
had regarding her former friends and coming in terms with what had happened.
Homework Assignment
 Practice ‘G.I.V.E’ exercise
 Fill out dysfunctional thought worksheet
 Make at least 2 phone calls with a friend before next session
 Write counteractive statements to negative thoughts
Session-3
Date: 14th Dec.2021

Like last time, we began with a feedback of the previous session, the client
admitted that the session had helped her especially in recognizing how her
perception errors make her interpret her interpersonal relationships and gaining
better control over her reactions to that. She stated that the dysfunctional thought
worksheet helped her understand that she may mis-interpret her parents actions
most of the time.
Then I proceeded to check the homework assignments she had done. She
had only done some of the work but it was a good effort none the less. I read in her
dysfunctional thought record worksheet that she had gone with some of her
university friends to a mall and felt as if they were leaving her out of purpose. But
the client hadn’t written an alternative thought in it so I discussed the issue with
her and made her complete the worksheet. I decided to being the focus of the
session back to her test related evaluation anxiety because the client reported it to
be one of her major issues. I introduced the problem solving and coping strategies
technique to the client and made her fill out the worksheet to understand the flaws
in her coping styles in this situation and helped her find more effective ones.
Following techniques were introduced:
 Coping Styles Worksheet
 Problem Solving Exercise
The client was taught to identify the specific aspect of her situation where she a
problem and focus on how she has dealt with it in the past. Then she was asked to
specify the outcomes of her actions and identify if they were in her favour or if
they had more drawbacks. The aim was to make the client better at problem
solving and effective decision making in this specific situation so that she has the
most benefit from the outcomes. Lucky the client had an upcoming test in the next
week so I asked her to keep that in mind and form a solution.
Client Response
The client has grown comfortable with the sessions and tries her best to make as
much improvements as she can. She is attentive and participates well. When asked
to identify her issues with tests and exams at first she was undermining herself and
stated ‘I just can’t do it, I know I can’t get better grades’. She was using her
distortions again which she quickly realized when I pointed out her previous
results in which she has scored above 80% aswell, the client realized that she was
only focusing on the negatives. She admitted that she gets so anxious that the entire
time is spent in worry rather than studying, she worries about a bad future result
before even trying to study. When asked to do the exercises and she wrote down
how she copes with test or exam situations, she realized that it hardly has any
benefits for her and a lot of drawbacks. After being retaught the faults in her
current cognitions related to the problem, the client was able to come up with some
solutions that she was going to try using in her upcoming test. After I helped her
fill the incomplete entry on her dysfunctional thought worksheet, she realized how
she had let her automated thoughts and distorted perceptions ruin her outing with
friends.

Homework Assignments:
 Use The solutions in the worksheet in the upcoming test
 Note down how you prepared for this test and the skills you used
 Practice G.I.V.E in interpersonal relationships
Session-4
Date: 21st Dec.2021

We started off with a feedback of our previous session and overall progress. The
client was eager to inform me about the test she had had. She stated that she used
the new coping strategy we had formed and was able to use her time to study for
her exam as effectively as she could. The client mentioned that she experienced no
anxiety attack over the course of this event, even tho it used to be a stressor for her
previously. She has showed a great overall progress.
I decided to base this session around the client’s depressive mood symptoms
and suicidal tendencies. Since it is a sensitive topic, I tried my best to follow which
ever direction the client wanted this interview to go. Important information about
her past was acquired and the client put more light on the fallout incident with her
friends that occurred two years ago. According to the client that incident had
changed her forever and is the reason for her self-destructive or suicidal tendencies
and depressive mood at times. She reported to hate what the event had done to her
and said she never regained her self worth after that. I did not want to invalidate
the clients feelings and emotional responses to the situation so I used unconditional
positive regard and made sure to take a very nonjudgmental approach. I
acknowledged what the client was saying and helped the client see the her
strengths and helped her understand that she is worth more than what her negative
thoughts related to herself say. I aimed to make the client understand some
negative core beliefs that she had internalized and help her detach those from her
self-image. Since the topic seemed to be too overwhelming for the client, I decided
I will teach her techniques in another session, however I did introduce the the
client to the Situation- acceptance exercise, so that we could analyzes this event
together and help her understand not to entirely take the blame for what happened
in the past and to accept the reality of what it was so that she can let go of some of
the guilt she’s been carrying. Lastly, I suggested an activity checklist for her to
follow if she felt comfortable so that there could be a reduction in her depressive
symptoms stopping her from participating in life.
Following technique was used:
 Situation Acceptance Excerise
 Activity Checklist
Client Response
Unlike the last two sessions, the client was back to being nervous and uneasy
during the interview, as expected with such a topic. She avoided eye contact at
times and was in a low mood. Her attention this time was also wavering, I could
feel that she was hearing what I hate to say but was finding it hard to accept or
believe. Nevertheless she still tried as much as she could on her behalf and
acknowledged where the issues were. For most she wanted to be heard on how she
felt and suffered because of the problematic event. After being given her space and
a nonjudgmental environment, she slowly toned down and was ready to see it from
another perspective and was open for discussion related to it. The client has low
self esteem so she found it hard to accept my efforts to show her that shes better
than her perceived self worth. However as the session progressed, she started to
understand these points from a logically point of view, hearing them out if not
accepting them fully. During the situation acceptance exercise, the client was
extremely nervous and practiced deep breathing without me having to ask her to.
She filled the worksheet and with my help tried to see that not all of it was her fault
and how she has been internalizing every bad things after the vent and blaming
herself for it. She found the activity checklist to be a bit childish but understood
soon that these were such simple tasks that people do to be progressive in their day
but she wasn’t doing them due to her depressive mood.

Homework Assignments:
 Fill the mood monitoring sheet for the week
 Do at least 8 activities, 2 from each section for the week
 Write a counteractive statement for whenever she has a suicidal or
depressive thought