PORTFOLIO

Clinical Internship

Submitted to:

[Mam Baneeha]

Submitted by:

[Minahil Malik]

Roll # 211520116

BS (Hons) 6th Semester

Session (2021-2025)

Humanities and Social Sciences Department

GIFT University, Gujranwala

 Department of Clinical Psychology
GIFT University, Gujranwala
Weekly Client Log (BSCP)
(To be signed off weekly by Clinical intern or On-site Clinical Supervisor and Head of the Department)

Name: Minahil Malik Batch: Fall 2021 Case No. 2 Name of On-site Supervisor: Mam Baneeha
Name of Internship Site: CHILD PROTECTION CENTRE Name of Dept. Supervisor: Mam Khushnood Fatima

Week # 2
Date Demographics Presentation/Diagnosis Assessment/Observation Therapeutic Contact Time
Intervention

Monday R.K.H 14 Years Irritability, Irritation Observation and Clinical Behavioral 9:30-12:30
07-06-24 male 4th grade Memory issue Interview Therapy.
Fifth birth order , loneliness Behavioral Psychoeducation
Hyperactivity Observation
Impulsivity HTP
DSM-5
Symptoms
Checklist
Case Reports
 Summary

The parents of 14-year-old Muslim R.K.H. gave up raising him and were unable to control his
behavior, so the boy was left in the care of a child protection bureau. He didn't seem to be changing
much at first, but later on, he started acting erratic, acting lonely, and refusing to go back home. He
also had trouble staying motionless and occasionally felt depressed and homesick. R.K.H. still has
trouble with memories and feelings connected to his family, despite significant progress. A
comprehensive evaluation was carried out, encompassing behavioral observations, clinical interviews,
and formal measures such as the Emotional Regulation Scale and HTP. The findings suggested that
R.K.H. would profit from intervention to deal with his behavioral and emotional issues. In order to
assist R.K.H. in creating appropriate coping strategies and managing his emotions, group therapy will
be used. Developing a close relationship and psychoeducation will foster comprehension and support
for both R.K.H. and his teachers. The intervention seeks to address family-related memories and
emotions, lessen hyperactive behavior, strengthen coping strategies, increase emotional control, foster
a sense of belonging, and assist R.K.H.'s social and academic growth. This intervention will give
R.K.H. the resources and assistance he needs to overcome his emotional and behavioral issues and
realize his full potential. The intervention will also prioritize boosting self-esteem, communication
skills, resilience, and stress management strategies. Supporting R.K.H. in creating a positive sense of
self and fostering wholesome interactions with others is the aim. By creating a welcoming and
nonjudgmental atmosphere, R.K.H. will feel at ease examining his feelings and coming up with ways
to control his actions. R.K.H. will have the ability to manage his emotions, form wholesome
connections, and succeed both personally and academically as a result of this intervention. Through
the resolution of his distinct requirements and obstacles, R.K.H. will acquire the self-assurance and
abilities required to prosper in every facet of life.
 Identifying Data (2nd level)

Name (initials) R.K.H

Age 14
Marital Status Single
Sex/Gender Male
Date Of Birth Not know
Occupation Not found
Language Punjabi
Race Asian
Nationality Pakistani
Religion June 7,2024
Assessment Date Mam Baneeha
Examiner 2
Case No

Reason & Source for Referral

The Child Protection & Welfare Bureau suggested the client for an overall examination and
management of his behavior and personality to determine whether there are any aspects of his
personality that require attention.

Presenting Complaints
Table 1

Duration Presenting Complaints

‫چھ ماہ سے‬ ‫مجھ سے قابو نہیں‬
‫چھ ماہ سے‬ ‫باتیں کرتا ہونمیں‬
‫چھ ماہ سے‬ ‫بےچینیمحسوس کرتا‬

Initial Observation

The client was seen in an educational environment. He was completing his homework. He was
animated and enthusiastic about our upcoming conversation. had a pleasant smile. He was seated
correctly, and when he played with his feet, his motor motions and body gestures were both fine.
Despite his poorly tailored attire, he had an excellent overall appearance.
 Developmental History of the Problem/ History of Present Illness

The client came in Child protection bureau 3 years ago. After his parent’s how are not
able to bear his behavior and put their hands off from him child protection bureau took
responsibility for him during this difficult period.
Background Information

Personal History

Client is a 14 years old boy living in Child protection bureau. His teacher reported that

He is a good boy; his teachers were satisfied with his performance.

According to them he is good in studies, his manners are good, don’t cause any

unnecessary trouble. Now he has 2 friends. He likes to play cricket and hide and seek with

his friends at evening and watch cartoons like doraemon, shiva shiva and motu patlu.

Premorbid Personality

We did not have any interaction with the family members of the client so in this case

we don’t know much about client’s premorbid personality. But his teachers told us about

the time he entered here He was sitting in corner and didn’t make friends and not like

playing. But now he is behaving like a good child to some extent.

Family History

Client has total 5 siblings, 2 brothers and 3 sisters. According to him his father is a good
father.

His mother is a good woman and they have happy family.

Educational History

We did not get access to his early education and he did not even remember. He got his

admission in Child protection bureau 3 years ago. Now he is in 4TH class standard.

His teacher’s feedback about him was that he is a nice boy, studies well. His writing is

very neat. His cognitive skills are good. He engages in class work very well. His favorite
subject was math.

Social History

The client had a best friend whose name is M.A and J.A. Both of them are in different class

but they live together in this institute. The client was engaging well with his class fellows.

Sexual History

R.K.H likes the girl how lives near to house. He rarely see her but he likes her very much he

also saw her in dream he said she is very beautiful.

Marital History

No history found.

Occupational History

No history found.

History of Past Psychiatry/ Medical Illness

The client does not have any kind of previous psychiatry of medical history.

Drug History

No drug history reported

Provisional Formulation

Based on the previously described background, R.K.H.'s symptoms align with

behavioral problems and emotional dysregulation were present; however, the symptoms did not fit the
DSM 5 TR criteria.

Assessment
The process of testing known as psychological evaluation employs a variety of methods in
order to generate hypotheses regarding a person's behavior, personality, and ability. Psychological
testing or administering a psychological battery to an individual are other names for psychological
assessment (Framingham, 2016). To evaluate the client's issues, a formal and informal psychological
assessment approach was employed. There are two categories of evaluation.
 Informal assessment
 Formal assessment

Informal assessment
It is a technique for gathering data regarding a client's behavior under typical circumstances.
This is accomplished without setting up test conditions as would be necessary for a formal evaluation.
Because it is conducted throughout time, informal evaluation is also known as continuous assessment.
Informal methods of evaluation are inherently subjective and are typically tailored to meet specific
assessment demands in treatment settings. They also typically need less resources, including time,
money, and experience, than nationally designed approaches (Cardozo & Magdalena, 1978).
• Behavioral observation;
• Clinical interview

Behavioral Observation
An assessment method called behavioral observation concentrates on how circumstances and
behaviors interact in order to influence behavioral changes. It places a strong emphasis on evaluating
undesirable behavior directly. It is a process that develops over the course of the treatment.
Understanding the conduct, impulsive mood, and reactions was the rationale for the behavior.
In order to determine the client's difficulties and arrange the management appropriately, observations
were made. Throughout each assessment session, the child's behavior was generally excellent.

Clinical Interview
 A component of psychological evaluation is a clinical interview. It gives a mental health
practitioner an opportunity to probe a client, have a conversation to find out more about them, and get
a sense of how they're feeling psychologically (Nikesh, 2015). A mental status exam, an admission
interview, an intake interview, or a diagnostic interview are some additional names for a clinical
interview. The purpose of the clinical interview was to learn more about the client's issue. A full
informational interview was held to learn about the client's premorbid personality, family history,
education history, past sexual experiences, and history of the current illness. The purpose of the
interview was also to identify the circumstances that contributed to, exacerbated, and maintained the
client's psychological issue. The client was quite in class after asking the questions about his mother and
family he began feel sad and his energy level became low than before. He started to write down his work I
asked him to leave everything and answer my questions with focus. Although he gives the wrong information
about his family. There were signs that he was faking his answers as they were very closely related to the real
world and his surroundings. We even took reassurance from this brother, the information he was providing was
not matching what his brother say’s. At start he was hesitating and not making an eye contact properly as he
was getting anxious but due to good repo building this issue soon got disappeared.

Mental Status Examination

Appearance:Wearing pent shirt. Appearance was good
Behavior: His behavior is normal smile in overall
Speech: He speak to politely. His volume, tone everything is normal
Mood: He didn’t show any hesitation he was good in session.
Perception: He is happy with his brother.
Thought form: No data found
Thought content: the client didn’t show urge to act upon the plan.
Cognition: His memory isn’t sharp; he was paying fully attention and concentration.
Insight: No, the client doesn’t feel his experiences as a result of illness

Subjective Rating Scale. Rate the client symptoms as reported by caretaker and
psychologist.
Table 3

Client’s Symptoms Pre-assessment Rating Scale (0-10)

Symptoms Ratings by Therapist Ratings by Care Taker

(0-10) (0-10)
Loneliness 6 7
Low self-esteem 7 7

Formal Assessment

This is a detailed report on a client's formal assessment, which included various tools like the
House-Tree-Person (HTP) test, Emotional Regulation Scale, and DSM-5 checklists. The report
provides insights into the client's personality, emotional dynamics, and potential behavioral
dysfunctions.

The HTP test results suggest that the client may possess a welcoming nature, be open to new
experiences, and have a desire for connection. However, there may be underlying conflicts,
fragility, and vulnerability. The client's drawings also indicate a sense of growth, positivity, and
strength, but also potential feelings of powerlessness and disconnection.

The DSM-5 checklist reveals that the client may be exhibiting symptoms of behavioral dysfunction,
including aggression, destruction of property, deceitfulness, impulsivity, emotional dysregulation,
social isolation, substance abuse, self-harm, reckless behavior, lack of empathy, defiance,
inattention, hyperactivity, and impulsive decisions.

This comprehensive assessment provides a foundation for understanding the client's complex needs
and developing a tailored treatment plan to address their unique challenges and promote overall
well-being.

DSM V Checklists for Specific Disorder. According to DSM5-TR of behavior dysfunction, client
might be falling under symptoms of Here are some common signs of behavior dysfunction.
Aggression: Verbal or physical aggression towards people or animals. Destruction of property:
Intentional destruction of property, such as vandalism or deliberate damage. Deceitfulness: Lying,
stealing, or cheating. Impulsivity: Acting on impulse without considering consequences. Emotional
dysregulation: Difficulty managing emotions, leading to mood swings or explosive outbursts.
Social isolation: Avoiding social interactions or having difficulty forming and maintaining
relationships. Substance abuse: Using substances to cope with emotions or stress. Self-harm:
 Engaging in self-destructive behaviors, such as cutting or burning oneself. Reckless behavior:
Engaging in risky or dangerous activities without considering consequences. Lack of empathy:
Difficulty understanding or relating to others' feelings or perspectives. Defiance: Refusing to
comply with rules or authority figures. Inattention: Difficulty sustaining attention or following
instructions. Hyperactivity: Excessive fidgeting, restlessness, or feeling constantly "on the go".
Impulsive decisions: Making decisions without considering consequences

Diagnosis criteria

Symptoms present in the client Status of symptoms

Aggression He had no signs of such aggression ✓

Deceitfulness He lied about his family ✓

Reckless behavior He had reckless behavior ✓

Hyperactivity He was hyperactive during section ✓

Impulsive decisions Yes, he had impulsive behavior ✓

Impulsivity He doesn’t show any clear signs ✓

Emotional regulation Scale

The Emotional Regulation Scale evaluates the client's capacity to manage emotions in various
situations, exposing challenges in emotional awareness and control. The scale comprises 10 items,
rated from 1 to 7, assessing two crucial aspects of emotional regulation: reframing negative emotions
(reappraisal) and hiding emotional expressions (suppression). The client's scores indicate moderate
abilities in both areas. They can somewhat effectively manage negative emotions by shifting
perspectives or focusing on positives (reappraisal score: 20). However, they also tend to suppress
emotions to a moderate extent (suppression score: 22), which, while occasionally useful, can lead to
emotional turmoil and relationship issues if excessive or prolonged.
Case Formulation
14-year-old boy is the client. He was so mischievous that he was put in a child bureau. Now that
he's adjusted well. Assistance is necessary for his health. The biopsychosocial model is followed in
the case formulation process.

Predisposing Factors
These are the factors that make a person susceptible to a particular condition. Like attachment
with mother, emotionally disturbed.
Precipitating Factors: are the immediate triggers or events that may have led to the current issues.
The precipitating factors could be the major precipitating factor is his separation from mother's
abandonment due to being missing, causing severe emotional distress. A sudden change in living
environment, from his home to the child bureau, played a significant role in triggering his emotional
response.
Perpetuating Factors: are the ongoing factors that maintain or exacerbate the problem. In this
case, the perpetuating factors could include the continued separation from his mother and the absence
of emotional support from his parents perpetuate his feelings of sadness and abandonment. Memories
of his past, including missing home and family, can be a persistent trigger for emotional distress, even
though he has adapted to his current environment. (P
 Case Conceptualization

Assessment
Informal
Presenting Complaints/
Symptoms  Behavioral Observation
 Clinical Interview
 Low Self-  Mental Status examination
esteem  Subjective Rating scale
 Baseline chart
Formal
 DSM-V-TR checklist
 Tools

Predisposing
Precipitating Perpetuating Protective
Factors Factors Factors Factors

Proposed Management Plan

 Rapport Building
 Psychoeducation Diagnosis
 Relaxation techniques
 Diagnosis

R.K.H. meets the diagnostic criteria for behavioral dysfunction as outlined in the DSM-5-TR. He
exhibits a persistent pattern of behavior issues, including inattention, impulsivity, and hyperactivity,
which interfere with his functioning and relationships. These symptoms have been present for at least
six months and have caused significant impairment in his social, academic, and occupational
functioning.
Client’s Prognosis
The Point in Favor
• Youthful resilience
• Normal cognitive functioning
• Supportive family relationships
• Positive attitude towards education
• Prolonged institutionalization
• Lack of parental guidance
• Academic setbacks
• Emotional regulation difficulties
• Limited social connections
The proposed management plan includes:

 Building a rapport with R.K.H. through active listening and trust-building

 Providing psychoeducation to R.K.H. and his caregivers about mental health and coping
strategies
 Teaching relaxation techniques and providing therapeutic support through individual and
play therapy
 Encouraging healthy social interactions and involvement in community programs
 Establishing a predictable daily routine and prioritizing building a trusting relationship

Long-term goals include:

 Family therapy to address underlying family issues and improve communication

 Supporting parents in understanding and meeting R.K.H.'s emotional needs
 Continued therapy to work on self-esteem and self-worth
 Encouraging involvement in extracurricular activities and regular follow-up sessions
Intervention strategies
It includes rapport building, psychoeducation, and behavioral therapy. Limitations of the
assessment include an unsuitable environment, interruptions, and the client's difficulty maintaining
concentration. Recommendations include providing an adequate environment, gathering more
information, and conducting a deeper investigation for better analysis. There are a number of useful
intervention techniques.
Rapport building
Warm and strong relationship between client and therapist to enhance the effectiveness of the
therapeutic intervention. Building rapport with your clients is one of the most important counselling
skills to possess. One observes body cues such as eye movements, voice tones, and body posture to
learn the thought processes behind them. Word selection used by customers reinforces the information
provided by body cues. Such rapport building facilitates the creation of mutually beneficial exchanges
(Nickels, Everett & Klein, 1983). Rapport was built by listening him actively, by verbally engage
with him, by using fewer encouragers, by asking open-ended questions, doing less interpretation.
Psycho Education.
In psychoeducation theoretical and practical towards understanding and coping with disorder
is elucidated to the client and his family. Moreover, it involves providing information about disorder’s
prevalence, its etiological factors, precipitating and maintaining factors to the family and people who
are around client most of time.
Behavioral Therapy Whereas cognitive therapy is focused on the negative thoughts that
contribute to depression, behavioral therapy is centered on changing behavior’s that affect emotions.
A central focus of behavioral treatment for depression is behavioral activation. This entails helping
patients engage in activities that will enhance their feelings of well-being.
Limitation
• The environment was not suitable for psychological assessment
 There was not any appropriate place for conducting assessment.
• The other people were interrupting during interview.
• The client kept losing his concentration from time to time.
Recommendations
• Environment should be adequate enough to get full attention of the client.
• More than sufficient information is required on behalf of the client.
 • Deeper investigation should be taken for better analysis.
 Session Report

The client is clearly exhibiting behavioral disorder. He is a boy of fourteen years old. residing for the
previous five years in a child protection bureau. His mother abandoned him at the child protection
bureau because he neglected his studies, and a relative encouraged her to check him into the agency
so he could concentrate on his studies. He said, "What can I do? Nobody cares about us. We have to
take care of ourselves on our own," to a trainee psychologist who questioned him about his life.
He replied he doesn't have many pals and doesn't express his sentiments with anyone when asked
about his circle of buddies.
 References

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 Sample reference

(In-text)

(Spritzer, 1980) or Spitzer (1980)

(Johnson-Laird, 1978) or Johnson-Laird (1978)

(Out-text)

Spitzer, R. L., Williams, J. B., & Skodol, A. E. (1980). DSM-III: the major achievements and an
 overview. The American Journal of Psychiatry

Johnson-Laird, P. N., & Steedman, M. (1978). The psychology of syllogisms. Cognitive

psychology, 10(1), 64-99.
 Other Suggestions

 Case report will always be written in past tense, Font style: Times New Roman
and Jameel Noori Nastaleen for Urdu
 Left margins 1.5 and remaining all the three areas (top, right, bottom) margin should be
1, Line spacing 1.5, non-justified
 Numbering will be done on the upper right corner; all references should be mentioned
at the last of case reports (i-e after compiling all the 5 cases)