1 BIO DATA Name: Age: Sex: Education: Occupation: No.

of Siblings: Birth order: Religion: Informant: REASON FOR REFFERAL The client was taken from the Addiction Ward of Punjab Institute of Mental Health and was referred for the purpose of psychological assessment and management. PRESENTING COMPLAINTS According to the clients: ___________________________________________________________________.1 ___________________________________________________________________.2 ___________________________________________________________________.3 ___________________________________________________________________.4 ___________________________________________________________________.5 ___________________________________________________________________.6 ___________________________________________________________________.7 ___________________________________________________________________.8 ___________________________________________________________________.9 According to the Informant: ___________________________________________________________________.1 ___________________________________________________________________.2 ___________________________________________________________________.3 ___________________________________________________________________.4 ___________________________________________________________________.5 A.S 23 Male Metric Jobless 2, (1 brother) 2nd Islam Uncle

2 ___________________________________________________________________.6 HISTROY OF PRESENT ILLNESS: Mr. A.S is 21 years old, unmarried male. The client has been suffering from the problems of increased intake of tobacco cigarette, and alcohol, insomnia, loss of appetite, weight loss, aggression, restlessness, agitation, low mood, easily fatigued, muscles aches/cramps, headaches, weakness, guilt/regret feelings. Due to excessive use of alcohol the clients functioning decline and he was unable to do work. His health has declined alarmingly. The history of present illness started in 2008 when the client was 18 years old; he developed friendship with drug users and started to indulge in bad activities. The client was in metric class when he started to smoke cigrates along his friends and gradually become dependent of smoking. The client belonged to a family of high socioeconomic status and has excess of money. The clients friends also belonged upper class. The clients reported that his father had died when he was one year old child. After the death of his father, the clients mother was shifted to her brother home. The clients alone brother had went to the England for horse riding. These events made client freer. He had complete freedom to move with friends and spent his time with them. Nobody, at home, had ever asked him about his routine of life. The client completely had lack of parents monitoring. The clients reported that he used to move with his friends all the day and at night. They all mutually arranged parties in which they drink together. The client told that in these parties they invited their girlfriends and they enjoyed these parties. The clients friends had great fun at these parties. These parties attract the more and motivate him to drink more and more. The client and his friends had a great interest in the girls. They often go on dates with the girls. The client reported that he also engaged in these activities and get enjoyed. The client was happy overall at this sort of routine of life. But the clients problems started when he started to take heavy dosages of the alcohol. The clients reported that he was taking a normal dosage of alcohol but when he fall in love with his neighborhood girl; he started to take excessive alcohol. The client was in a mature age when started to love that girl.

3 He was made in his love. He often brought precious gifts, jewelry and cloths. They often go at dates and enjoyed the company of each other. During the interview the client had disclosed that he also had sex with her. On the other side, the girl showed that he was also in love with him but in fact she was betraying him. Soon, the client realized the feelings of his beloved. It was unbearable for the client and he became depressed. He started to take heavy dosages of alcohol. But the client was still serious about her and wants to marry with her. He told his beloved that he wants to marry with her and she also accepted his proposal. She asked him that she was ready to marry with him but his mother should come at her home with his proposal. The client agreed and promised the girl. When client told about his love story to his mother and asked her to go his beloved home with his proposal. The clients mother annoyed at his desire and refuse to go his beloved home. The clients mother told to client that they never marry in a low socioeconomic family and it is wise to him to forget her. This entire situation made the client depressed and distressful. He stopped to go outside the home and started heavy drinking. The clients mother became anxious at overall situation. The clients refused to take his meals and started to spent sleepless nights. He wanders whole the night along his friends and takes heavy dosages of drinks. The client reported that due the habit of wondering and alcohol usage he was arrested many times. But due to his strong and well to do family status he was resealed soon. The clients mother was too upset at the clients condition. She understands the client many times to avoid his friends company but he always ignored her advices. The circumstances were gone badly to clients mother and she did not like such attitude of his son. She decided to cure the clients drinking habit and she took him at the Punjab Institute Mental Health (PIMH) for proper cure of his alcohol addiction. Here the client was admitted after some assessment and now client was at the Drug Addiction ward of the PIMH. FAIMLY HISTROY: The client belonged to a well to-do family and had an upper socioeconomic status. They had all luxuries of the life. They were spending happy life with excess of wealth. They never bother for their expenses. They live in a nuclear family system.

4 The client reported that his father died in 1987 due to heart attack. At the death of his father he was one year old child. His father education was graduation. He had his own business. According to the client his father had a strong personality. He was the hardworking person. He loved his both children too much. His father was found of horse riding. He often had been gone to race course club for races. According to the client his father was the member of race course club. There he used to like drink with his friends. In the death of the clients father drinking was main contributing factor. His fathers relationships with this wife were congenial and satisfactory. understanding with her wife and cared for her a lot. The clients mother was alive. Her age was 30 year and she was a house wife. Her education was graduation. She had been living in his brothers house after the death of his husband. She had a kind and loving nature personality. She always takes care of his children. She had no conflict with his husband. But she had a conflict with the client on the issue of his marriage. The clients likes a girl and want to marry with her but his mother was not agreed. Overall she had a soft, loving and caring personality. Her physical and psychological health was quite good. The client had 2 siblings; 1 brother. The first born was his elder brother. He was 26 old male. He was unmarried. His education was graduation. He was a good horse rider. During his studies he had taken the horse riding training. After fully trained in horse riding he went to England. There, he joined the horse riding club and started to take part in the races. He was a professional horse rider and it was also his source of income. He was happy and living a good life. He was the sole earner of his family. He earned 1, 20,000 monthly which is enough for him and his family needs. According to the client his brother loved him too much. He always sends him his pocket money separately. He had a friendly and satisfactory relationship with client. He had a good physical and psychological health. The second borne was the client himself. He had good mutual

5 PEERSONAL HISTROY Birth and Early Childhood: According to the clients mother his birth was normal. The health of clients mother was good at the time of his birth. She had no prenatal and postnatal problems. The clients birth was normal at home. Her birth weight was average and the mother didnt suffer from any illness during pregnancy. He achieved all the milestones at the appropriate age. The client started talking at the age of 9 month and same like client started sitting, crawling, standing, walking and using toilet at appropriate age. According to the clients mother he was very sensitive and aggressive child. He became easily angry at little things. Educational History: The client got admission at the age of 5 years in school. He was happy at that time period. The client reported that he was a bright student and always got positions. According to the client he had been participating in extracurricular activities. His teachers admired him and like him. He had good relationships with his teachers. According to the client he had friendly relations with all his class fellows and used to play with them. He also used to help them in their homework and in the preparations of the exams. Social History: The client had strong social ties. He used to spend most of his time with his friends outside the home. The client reported that his social relations spoiled his life. He had many friends in his life. All of them belong to upper class. The client reported that he likes the company of his friends. He spends much time with them. He used to do wandering all the night with them. They mutually go to clubs. All of his friends were drinker and they drink regularly. The client also drinks with them. They were happy with their habit of drinking. They mostly drink in a company. They all fond of late night parties and attend them regularly. The clients had happy and satisfactory relationships with his friends. They often arrested due to their habit of drinking. But they released soon due to their status influence.

6 Sexual History: The client reported that he reached puberty at age of 16 years. He was exited at the developmental changes and not confused on these changes in body. He got information related to sexual information from his friends. He was found of reading romantic novels and watching romantic movies. He had great interest in opposite sex. The client reported that he often flirt the girls along with his friends. They had sexual relationships with many girls. The client also took part in these activities. The client reported that he got his first sexual experience with a girl who lived in his neighborhood. According to the client she was a beautiful girl and he was in love with her. He often used to gift her expensive articles. The client also reported that he also used to give her money. The girl belonged to a low socioeconomic status. But the clients feelings and affections with her was true. On the other side the client a source of money to her. She always demands gifts, money and cloth. The client had become blind in his love want to marry with her. The client discussed all the matter with his mother and asks her, he wanted to marry with her. But the clients mother did not accepted the proposal. She was not even refused but also warned him to remain away from her. On the other side that girl also betraying him. He was so upset at overall situation. He used to drink in heavy dosages. He still loves that girl but his mother was not agreeing to accept his proposal. Occupational History: The client reported that he was unemployed. After his matriculation, he started to take training of horse riding like his brother. But he could not keep himself to carry on it. He left the training after 3 months due to his drinking habit. He felt that he was unable to get this training. He felt uneasy at the training. His brother wants to see him as horse rider. But the excess of wealth and his bad company made it difficult for him. Overall, he had no interest in work. PREMORBID PERSONALITY The client reported that his life before starting drinking was quite normal and happy. He was living a joyful life and spends most of his time with his friends. According to the client he uses to go outside on his motor bike with friends. His mother is happy with him

7 because he is an obedient son. His uncle was also happy with him. The client reported that he often remembers his father. His fathers memory makes him sad. The clients reported that he is fond of horse riding and wants to become a horse rider like his brother. The clients mother reported that his son is a good child but the bad company makes him sick. She also reported that the client is a good student in his studies and also offer his prayers five times in a day. ASSESSMENT Informal Psychological Assessment Clinical Interview Behavioral Rating of Client Symptoms Mental Status Examination Baseline Chart

Formal Psychological Assessment Intellectual Assessment (Standard Progressive Matrices Test) Personality Assessment (Rotter Incomplete Sentence Blank ) Diagnostic Assessment (Minnesota Multiphasic Personality Assessment) INFORMAL PSYCHOLOGICAL ASSESSMENT Clinical Interview Informal psychological assessment was carried out in the form of interview of the patient. In different sessions the client was examined. His nature and severity of the illness was been explored. Mental status examination: The client was a weak boy of 21 years. He was not sitting in relax posture. He reported that he was feeling pain in his body and there were crams as well. He was in uneasy posture. His face was showing fatigue and tiredness. The color of the hair of client was black and texture was not good. He was wearing shalwar kameez. His height was normal but body weight was low. The client was maintaining good eye contact. He was cooperative and was not looking here and there. His facial expressions were sad. He was

8 depressed. The client was friendly. He was looking older than his apparent age. The motor movement of the client was good. The client showed no psychomotor agitation. Due to absence of drugs his motor movements were slow as he was feeling pain and crams in the body. The rate of his speech was fast. The client was interested to indulge in conversation at a very good pace but his condition was not allowing him. The volume of the clients speech was good. He was speaking in high tone. No stammering or stuttering was observed. The client rated his mood at 5 and he was looking quite upset. Stream of thought was good the thought content was his girl friend and substance he abused. No hallucinations or delusions were observed. The client clearly lacked in abstract thinking. He was not been able to tell the meaning of proverbs. The client had good attention and concentration as well. The clients orientation about time, place and person was intact and he answered correctly all the questions. The clients memory was also intact and he was able to tell about recent, recent past and remote memory. His judgment was also good Rating of the symptoms of the Client Table: Clients, and his Mothers (0-10) Rating of the symptoms of the Client S. No. 1 2 3 4 5 6 7 8 9 10 Symptoms Insomnia Loss of apatite Aggression Wight loss Easily fatigued Work desire Headache Muscle crams Restlessness Low mood Clients Rating 7 6 8 6 7 5 7 8 8 9 Informants rating 8 7 9 7 8 6 8 9 8 8 Mean score 7.5 6.5 8.5 6.5 7.5 5.5 7.5 8.5 8 8.5

Base Line Charts: A baselines chart consists of repeated measurement of the natural occurrence of a target behavior prior to the introduction of the treatment (Splegler and Guevermont, 1998). For the client base line charts were designed measuring anger and headache. According to the base line chart the client had lost pleasure in daily activities, is experiencing headache. The charts were made and rated for a week to observe and note down the clients acts as a result of headache and aggression his average intensity of the thought was 10 in the

9 whole weak. FORMAL PSYCHOLOGICAL ASSESSMENT INTELLECTUAL ASSESSMENT Standard Progressive Matrices Test administration: The test was administered on April 13, 2011, in ventilated room. The client was sitting on a chair and the instructions were given according to the manual. He took 30 minutes to complete the test. Behavioral observation: A.S was a 23 years old male. He was an averaged looking young adult of normal heighted and medium physique. He entered the room, walk fastly. He was dressed up in Shalwar Kameez and was unshaved. He took his seat and passed a smile. He was cooperative and answered all the questions and was following the instructions that were given to him. He completed the test in 13 minutes. Quantities Analysis: Administration of the SPM Showing the Subjects Score Analysis Raw Scores Percentile Grade 31 25
th

discrepancies Time 0,1,-2,-1,1 Taken 30 minutes

IV

Qualitative Analysis: The subject total row score of 31 which corresponded to 25th percentile rank. The percentile rank shows the position in contrast with high and low achievers. The 25th percentile shows that the performance of the client is intellectually below average in the test. This means that he has surpassed 24 % of his age group and has below average intellectual capacity, comprehension and reasoning ability. And 75 % people of his age are above him. It reflects that his capacity meaningless figures by seeing relationship between the working at adequate level. According to his percentile and row score he receives an IV Grade. It indicates that the client is definitely average in intellectual capacity.

10 The distribution of score on five sets shows that there are some discrepancies. The difference between the obtained and expected scores on set A, B, C, D, & E is 0, 1, -2, -1, 1.These discrepancies show that client test performance is consistent and his intellectual capacity as indicated by test is valid. The client result is reliable and indicates that the client is definitely below in average in intellectual capacity and can be correlated well with his background information. The client performance on Standard Progressive Matrices relate to his educational background and social status. PERSONALITY ASSESSMENT Rotter Incomplete Sentence Blank Behavioral Observation Mr. S.A was 23 years old young man. He was bored to hear about the test. After the some motivation given to him he was agreed to complete the test. He was anxious about test why it was so lengthy. He answered every question calmly. He made a good cooperation in spite of his boredom. The client was given instructions according to the manual. The time taken by the client was considerably more than the normal subjects. He was thoughtful and suspicious by his gestures. He took 1hours and 30 minutes to complete the test. He was curious to know the reason of the test. Test Administration The RISB was administered on April 13, 2011 in a well-lit ventilated room in PIMH. The client was sitting on a chair and instructions were given according to manual. The room was free of distractions. Results Quantitative Analysis Positive responses P1 1 P2 8 P3 5 Total 14 Conflict responses C1 6 C2 6 C3 7 Total 19 Neutral responses N 6

Total

11 %age 35% %age 50% %age 15%

Raw Score 126 Qualitative Analysis Familial Attitude

Cut off Score 135

Remarks Normal

There are some items like 2 and 30 showed the conflict related to the familial attitude. These items showed the conflict related to his family and his habit of drug addiction. Item no 2 showed his conflict that due to his problem of drug addiction, he had to face the persuasion hate of family members. Item no 30 showed conflicts related to his related habit of drug addiction. He was really upset at his problems. Social and Sexual Attitude The items showed by items 14 and 19 the conflict related to the social conflicts. Item 14 showed the social attitude with his past school life as it was good that showed that the client was happy in the past but now a days he lose his mental health. Item 19 showed conflicts related to the people as they scourge and hat him as he was addicted. General Attitude Some items showed the conflict related to his general attitude. For example items showed general attitude are 5 and 9. Item no 5 showed his conflict that due to his problem of drug addiction, he had to face the persuasion hate of family members. Item no 9 showed conflicts related to his habit of drug addiction. He was really upset at his problems and felt regrets over his attitude. Character Traits Some items showed his character traits for example items 1, 18 and 32.

12 Item 1 showed his characteristic related to his extrovert traits of personality as he likes to meet people and have their company. Item 18 showed his character trait related to his nerves as they were weak. Item 32 showed his character trait related to his worries. Summary The client score indicated that he is normal as his score as 126 below from cutoff score of 135. However, he showed some conflicts related to his familial attitude as conflicts related to his familys persuasion over his drug addicted behavior He also showed conflict related to social and sexual attitude as people showed hate to him. General traits showed by him as he, had worries and his nerves were weak and he was may be target to stress and anxiety. DIAGNOSTIC ASSESSMENT Minnesota Multiphase Personality Inventory (MMPI) Behavioral Observation Mr. S.A was 23 years old young man. He was bored to hear about the test. After the some motivation given to him he was agreed to complete the test. He was anxious about test why it was so lengthy. He answered every question calmly. He made a good cooperation in spite of his boredom. The client was given instructions according to the manual. The time taken by the client was considerably more than the normal subjects. He was thoughtful and suspicious by his gestures. He took 1hours and 30 minutes to complete the test. He was curious to know the reason of the test. Test Administration The MMPI was administered on April 13, 2011 in a well-lit ventilated room in PIMH. The client was sitting on a chair and instructions were given according to manual. The room was free of distractions. Quantitative Analysis

13 Scales ? L F K 1-Hs 2-D 3-Hy 4-Pd 5-Mf 6-Pa 7-Pt 8-Sc 9-Ma 0-Si Raw Scores 22 4 16 09 20 33 24 39 19 24 33 26 30 30 T-Score 22 43 64 40 60 71* 59 88* 33 76* 72* 51 72* 48

Validity Scales L Scale The L scale encompasses 15 items and detects a deliberate and rather unsophisticated attempt on the part of the individual to present him in a favorable light. It suggests whether or not an individual is presenting, either consciously or unconsciously, entirely perfectionist view of himself. The client raw score is 4 and T score is 43 on this scale which is low score. Low score is also seemed in unconventional normal people. The score is also associated with the self confidence and willingness to admit minor faults and shortcomings. F Scale The F scale comprises of 64 items and identifies deviant or a typical ways of responding to the test items. The client obtained a raw score of 16 and T score of 64. High score in this range is indicative of individuals who may be malingering, exaggerating symptoms as a plea for help, may be quite resistant to testing procedure or may be clearly psychotic by the usual criteria. K Scale The client scored a raw score of 9 and T score of 40. Low K scores may be allied with faking bad profile, exaggerating problems as a plea for help, critical towards self and others, self dissatisfaction, ineffectiveness in dealing with problems of daily life, showing

14 little insight into own motives, and behaviors and suspicious about motivation of other people. ? Scale The question score is a validity covering of the total number of items put in the Cannot Say category. The client did make use of cannot scale and it indicates that he has responded to all except 22. (F-K) Gough (1950) suggested a method of invalidity by taking disparity of raw F and K scores and his difference could serve as a useful index for detecting fake bad profile. It indicated that if the score is greater than +9 or less than -9 than the individual was either faking bad or faking good. Carson (1969) suggested that a cut off score of +11 yields a more accurate identification of fake bad profile rather than 9. The differences of raw F and raw K scores of the client are +7. Positive may point out that the client may be psychotic or severely disturbed. This can be supported by his case history that he is having symptoms of auditory hallucinations. Clinical Scales Depression (D-2) The 60 items in scale cover a wide array of behaviors and deals with psychotic symptoms. The client scored raw score of 33 and a T score of 71 which indicates depressed and blue. The symptoms showed physical complaints weakness, fatigue and loss of energy. High scores described as introverted, shy, timed and secretive. A life style characterized by withdrawal and lack of intimate involvement with other people is common. Psychotic Deviate (Pd-4) The prominent elevations of the scores appear on Scale-Pd where in the client has received the raw scores of 39 with corresponding T-score of 74. It is termed as high elevation, showing that he has cold relationship with family and society. He is indecisive, angry, rebellious, and impulsive, alienated and has strong disliking for rules and regulations. In Freudian terms, these are individuals with little or no effective super ego they have been unable to incorporate the standards of society into their own consciences. People with high Pd score, are unable to form close relationships, have difficulties in

15 marriage and work, show poor judgment, act impulsively and demonstrate egocentric tendencies. Paranoia (Pa-6) This scale consists of 60 items and deals with paranoid symptoms. The client scored a raw score of 24 and T-score of 76. High score on scale 6 (Pa) suggests suspiciousness and over sensitivity and may indicate paranoid delusions, as well as depressive feelings, but without the feelings of responsibility that are typically projected onto others. People may have delusions of reference, grandeur or persecution. Such patients are often angry or fearful and may plot revenge on others. They may be dangerous to others or even to themselves as a result. Other Scales The clients score on scales 3, 5, 6, 9 and 0 is 59, 33, 59, and 48 respectively which falls in the moderate range. The client has masculine preferences in work, hobbies, and other activities. The client may be tough, aggressive and vigorous. The client may have a narrow range of interest and has limited intellectual ability. The client may not interact well socially. The client may be immature and unrealistic. The client may report chronic fatigue and physical exhaustion. The client may be moderately depressed, anxious and tense. The client may lack of self confidence. He may be reserved and timid. The client may be sensitive to what others think about him.

Two Point Codes 46/64 Patients with this 46/64 code are hostile, immature and emotionally distant, and have severe problems with adjustment. Their behavior can be irritable and unpredictable, and they may act out in distrustful ways. Such acts, however are generally poor planned and impulsive, and be vicious. These individuals can be insecure, socially withdrawn, and socially isolated. The world is seen as rejecting place. They accept the little responsibilities for their own behavior and they rationalize excessively blaming their difficulties on other people.

16 NEUROPSYCHOLOGICAL ASSESSMENT Benton Visual Retention Test Behavioral Observation Mr. S.A was 23 years old young man. He was bored to hear about the test. After the some motivation given to him he was agreed to complete the test. He was anxious about test why it was so lengthy. He answered every question calmly. He made a good cooperation in spite of his boredom. The client was given instructions according to the manual. The time taken by the client was considerably more than the normal subjects. He was thoughtful and suspicious by his gestures. He took 1hours and 30 minutes to complete the test. He was curious to know the reason of the test. Test Administration The BGT was administered on April 13, 2011 in a well-lit ventilated room in PIMH. The client was sitting on a chair and instructions were given according to manual. The room was free of distractions. BVRT Scores on assessment Showing the expected Correct Scores, according to age range of 15-49 years, estimate IQ, obtained Correct Score and difference between the expected correct scores and obtained correct scores according to the pre-calculated norms of administration A and remarks.

Age 21

Expected IQ 95-109

No of expected No of obtained Differen category correct score 9 correct score 8 ce 1 Average

Remark s As Expected

BVRT Scores on assessment Showing the expected error Scores, according to age range of 15-49 years, estimate IQ, obtained error Score and difference between the expected error scores and obtained error scores according to the pre-calculated norms of administration A and remarks. Age Expected IQ No of expected No of obtained Differen categor error score error score ce y Remarks

17 21 95 -104 5 2 3 High Average Qualitative Analysis: The qualitative analysis showed that the subject obtained correct score was 8 which was dissimilar to the expected correct score with an Average IQ. The subjects score on BVRT indicated that he falls in Average category that suggests satisfactory visual retention. An analysis of the subject quantitative results further indicates that his number of obtained error score was 2 and the expected error score was 2. Thus the differences between errors score 0, which indicate that the subject has no problem in visual retention. It also provides an estimation of her IQ which is within the range of 95 - 105 categorized him as mentally High Average. 0Table 5: BVRT Scores on assessment Table 5 is showing the number of error according to the error category. Error Omission Distortions Perseveration Rotations Misplacement Size error Total Summary: The Benton visual retention test was used to assess the neurological functions of the client. The test assessed visual construction skills, visual memory, and visual perception. The qualitative analysis showed that the client did not show any kind of error and fall in the category of none defective. Due to his therapy and medication, there was a change in his condition so it also showed by the scores that he did not show any kind of error. His visual construction skills, visual memory, and visual perception skills were normal. TENTATIVE DIAGNOSIS USING DSM-IV-TR Axis I 303.90 Alcoholic Dependence Left 2 1 -----Right 1 ------Total 3 1 -----As Expected

18

Axis II Axis III Axis IV friends) Axis V

V 71.09

No diagnosis None problems related to the social environment (influence of

GAF= 31-40 (current)

DIFERENTIAL DIAGNOSIS Substance disorder is distinguished from non nonpathalogical substance use (e.g social drinking) and from the use of medications for appropriate medical purposes. Repeated episodes of Substance Intoxication are almost invariably prominent features of Substance Abuse or Dependence. However, one or more episodes of Intoxication are not sufficient for a diagnosis of either Substance Dependence or Abuse. If the symptoms are judged to be a direct physiological consequence of a general medical , the appropriate Mental Disorder Due to a General Medical Condition should be diagnosed. PROGNOSIS The clients prognosis was promising and good because he appeared to be very motivated and showed full co-operation. He wanted to get relief as soon as possible and wanted to start a new life and has plan to get further education and then getting married, so it seems to be have good insight to some extent. CASE FORMULATION: The client was 21 years old single male with the education up to metic with the complaints of alcoholic dependency. The client was well dressed, neat and clean. He showed full co-operation in first meeting. He appeared to be friendly and cooperative. He maintained proper eye contact and appropriate posture in all sessions. His speech and communication was appropriate though at some points he showed some pauses. His

19 speech was clear, fluent and coherent. He explained his problems and history in detail and emphasized a lot on his friends role in his that current condition. He also reported loss of energy, fatigue and stiffness of body and neck repeatedly. But he wanted to get rid off from this situation as soon as possible. He was overall well aware and well oriented with time, person and place. He did not report any memory problem but reported lack of concentration in his school time and during job. He was well aware that he has some problem and was ill and here to seek for psychological help and treatment so he cooperates in all things. MSE, case history interview, MMPI was used to assess diagnostic/screening criteria for assessment and for intellectual functioning SPM was used, and to evaluate the personality of the client, the RISB was administered on the client to assess his personality, BVRT used to assess the clients neuropsychological functioning. The clients history suggested that the leading predisposing factors of his alcoholaddiction was his age, gender, and parental drug abuse history. Many researches indicate that the age is a common factor of drug abuse. As the child reaches in the adolescence he involved in such drug abusing behavior starting from smoking and taking beverages. For this kind of behavior society and peers group have strong impact. As the case, with client he belonged to an upper class family and had peer relationships with such guys whom are also belonged to upper class family and in the habit of drug abuse. Thirteen- to fifteenyear-olds are at high risk to begin drinking. According to Johnston, (1995) results of an annual survey of students in 8th, 10th, and 12th grades, 26 percent of 8th graders, 40 percent of 10th graders, and 51 percent of 12th graders reported drinking alcohol within the past month . Binge drinking at least once during the 2 weeks before the survey was reported by 16 percent of 8th graders, 25 percent of 10th graders, and 30 percent of 12th graders. Young people at highest risk for early drinking are those with a history of abuse, family violence, depression, and stressful life events. People with a family history of alcoholism are also more likely to begin drinking before the age of 20 and to become alcoholic. Such adolescent drinkers are also more apt to underestimate the effects of drinking and to make judgment errors, such as going on binges or driving after drinking,

20 than young drinkers without a family history of alcoholism. (Hingson & Heeren 2006). ). A potentially powerful predictor of progression to alcohol-related harm is age at first use. Evidence suggests that the earlier the age at which young people take their first drink of alcohol, the greater the risk of abusive consumption and the development of serious problems, including alcohol disorders (Chou & Pickering, 1992). As the age was concerned with onset of the clients alcohol abuse, clients gender is also a contributing factor of his problem. Many researches indicate that the alcohol abuse is more common in males as compared with females. Drinking is associated with displays of masculinity or male camaraderie, this may encourage male drinkers to deny or minimize problems resulting from their drinking, or to regard drunken behavior as normal or permissible (Capraro, 2000; Nayak, 2003; Nghe, Mahalik, & Lowe, 2003), even when it leads to violence (Graham & Wells, 2003; Hunt & Laidler, 2001; Tomsen, 1997). At the other extreme, surveys in many different populations consistently find that men are more than twice as likely as women to report heavy episodic drinking (or "binge" drinking, of at least 60 grams of ethanol in a day) (e.g., Janghorbani et al., 2003; Malyutina et al., 2001; Miller et al, 2004; Neumark, Rahav, & Jaffe, 2003; Welte et al., 1995). Recurrent alcohol intoxication is much more prevalent and more frequent among men than among women (Hao et al., 2004; Makela et al, 2001; Rehm et al., 2001). Consistent with gender differences in heavy drinking, surveys in many countries find that men are more than twice as likely as women to have alcohol use disorders. Men are much more likely than women to report diagnosable alcohol abuse, either currently (e.g., Bijl et al., 2002; Dawson, Grant, & Stinson, 2004; Hao et al., 2004; Kringlen, Torgersen, & Cramer, 2001; Yamamoto et al., 1993) or as a lifetime experience (Kawakami et al., 2004; Meyer et al., 2000). Men are also much more likely than women to report diagnosable alcohol dependence, currently (e.g., Bijl et al., 2002; Hao et al., 2004; Hasin & Grant, 2004; Kawakami et al, 2004; Spicer et al., 2003) or as a lifetime experience (Dawson & Grant, 1998; Heath et al., 1997; Kawakami et al. 2004; Meyer et al, 2000). The most common hypotheses to explain why men and women differ in their drinking behavior argue that alcohol consumption both symbolizes and enhances men's greater power relative to women (McClelland et al., 1972). Alcohol consumption, particularly in large quantities, has been an emblem of male superiority, a privilege that men have often

21 reserved for themselves and denied to women (Martin, 2001; Nicolaides, 1996; Purcell, 1994; Suggs, 1996, 2001; Wang et al., 1992; Willis, 1999). Alcohol consumption in allmale groups may affirm the privileged status of being a man rather than a woman (Campbell, 2000). The third underlining factor of clients alcohol abuse was the genetically related to his problems. According to the client, his father was also a regular drinker. The clients reported that his father has many friends at the race course club and he used to take drinks with them. The genetic factor always played a significant role in developing psychological problems. Many investigations showed that the genetic predisposition is related to the developing psychological problems later in the children. The idea that alcoholism runs in families is an ancient one. In recent decades, science has advanced this idea from the status of folk-observation to systematic investigation (Roe, 1944 and Goldman, 1986). In the 1970s, studies documented that alcoholism does run in families (Goldwin & Cotton, 1979). Researchers investigate possible genetic components of alcoholism by studying populations and families as well as genetic, biochemical, and neurobehavioral markers and characteristics (Cloninger, 1990 and Mcgue, 1991). Two major methods of investigating the inheritance of alcoholism are studies of twins and of adoptees (Pikens & sivkis, 1991). Twin studies compare the incidence of alcoholism in identical twins with the incidence of alcoholism in fraternal twins (Hrubec, 1981 & Pikens, 1988). If there is a genetic component in the risk for alcoholism, then identical twins, who have identical genes, would be expected to exhibit similar histories of developing alcoholism (or not developing alcoholism). Fraternal twins, who are genetically different individuals born at the same time, would be more likely to differ in their tendencies to develop alcoholism. In general, researchers using the twin method have found these expectations to be true. The precipitating factors of clients alcohol abuse are his social circle, friends and peer. The client reported that he has many friends and all of them are alcohol users. The client also started to take drinks with them. The researches indicate strong association in drug abuse and social influence. Social factors such as peers, friends and availability of drug are main contributing factors in adolescence. Alcohol use continues to be an important

22 public health problem. Recent national survey data indicate that 41% of current 8th graders, 62% of 10th graders, 73% of 12th graders, and 85% of college students have used alcohol (Johnston et al., 2007). Even more troubling is that 11% of 8th graders, 22% of 10th graders, 25% onf12th graders, and 40% of college students reported heavy episodic drinking. Psychosocial factors play a key role in the onset and developmental progression of alcohol use. These include social influences from parents and peers, perceived drinking norms, and positive expectancies. Moreover, research has shown that social influences to drink outranked cognitive and behavioral factors in predicting initial involvement with alcohol longitudinally (Ellickson and Hays, 1991). According to Social learning theory (Bandura, 1977) provides a useful theoretical framework for understanding the role of social influences, suggesting that adolescent alcohol use is a learned behavior acquired through a process of observation, modeling, imitation, and social reinforcement. Peers and friends also exert a potentially powerful social influence on adolescent drinking behavior. Adolescent drinking has been associated with alcohol-using peers in predominantly white samples (e.g., Kandel, 1986; Kandel and Andrews, 1987; Sieving et al., 2000). Research indicates that social influences to drink stem from both the initial selection of friends (i.e., choosing friends) and the subsequent maintenance of friendships with positive reinforcement and other rewards (Windle, 1999). According to the clients the social environment in which is living is highly suggestive of such behaviors. The social environment selection have great role in developing alcohol abusive behavior. Although social influences typically have been conceptualized as directly shaping drinking behaviors in adolescents, it is likely that individuals are not passive recipients of environmental influences and that the association between environment and drinking behavior is reciprocal rather than unidirectional; that is, individuals are affected by social environments, but they also select the environments to which they are exposed. Selection of social environments that are conducive to drinking may play an important role in alcohol use and problems (Britt & Campbell, 1977; Wood, Maddock, Hallak, Mitchell, & Stevenson, 2000) and may account, in part, for the effects on alcohol use of

23 certain demographic and personality characteristics that may influence social selection. Evidence from both the genetic and the social psychological literature suggests that individuals may present to a social environment with specific (possibly heritable) individual risk factors, which may interact with the environment to result in increased alcohol consumption (e.g., Fitzgerald & Zucker, 1995; Legrand, McGue, & Iacono, 1999; Maisto, Carey, & Bradizza, 1999; Searles, 1988). Within this interactive framework, an environmental selection perspective suggests that dispositional or static characteristics may influence behaviors directly and indirectly by affecting the types of environments to which one chooses to be exposed (Robins, Elliott, & Pattison, 2001; Searles, 1988). Recent work in the area of social network models of behavior points to evidence that social networks are, in fact, chosen as a result of the particular sociodemographic, personality, or other types of characteristics of the individual who selects them (Robins et al., 2001). As a result, these selected environments may support and enhance predispositions to certain behavioral outcomes. The maintaining factor of clients alcohol abuse is his motivation for drinking. The clients reported that he had a great desire for taking alcohol. He reported that the he used to drink to avoid his problems such as to forget his beloved response and his conflict with his mother. He reported that he was unable to give up the drinking behavior; it is the only way to cope with his problems. Researches indicate that the individual motivations plays important role in maintenance of alcohol abusive behavior. A large body of research on the etiology of adolescence drinking has identified social and psychological correlates of alcohol use and misuse (e.g., Baer & Carney, 1993; Fromme & Ruela, 1994; Wechsler, Dowdall, Davenport, & Castillo, 1995). Furthermore, many have stressed the role of specific motives for drinking in this population (Carey & Correia, 1997; Karwacki & Bradley, 1996; MacLean & Lecci, 2000; Stewart & Zeitlin, 1995). According to Motivational models assert that an individuals reasons for engaging in a behavior are important in both the initiation and perpetuation of that behavior. Applications of motivational theory to drinking behavior have consistently supported the importance of motivational factors in alcohol use across adult (e.g., Abbey, Smith, & Scott, 1993; Carpenter & Hasin, 1998), adolescent (Bradizza, Reifman, & Barnes, 1999;

24 Windle, 1996), and college (Carey & Correia, 1997; Kassel, Jackson, & Unrod, 2000; Ratliff & Burkhart, 1984) populations. Different types of drinking motives have been delineated. Most commonly, drinking motives have been categorized according to affective dimensions (e.g., drinking to enhance or stimulate positive emotion, drinking to cope with negative emotion). However, motives pertaining to social factors (social reinforcement) also have been thought to be important in understanding drinking behavior. In 1988, Cox and Klinger posited a theoretical model of drinking motives that took into account the interplay between these motives and specific psychosocial antecedents. These authors hypothesized that factors such as mood and mood-relevant expectancies contributed to the motivation to drink alcohol, playing a critical role in the determination of alcohol use. Cooper, Frone, Russell, and Mudar (1995) proposed and tested a motivational model of drinking that was consistent with Cox and Klingers theoretical model. Using structural equation modeling procedures, they tested whether distinct motives (enhancement and coping) were associated with alcohol involvement and whether they played a central, intervening role in the relationship between more distal psychosocial factors, such as alcohol outcome expectancies (i.e., social enhancement and tension reduction), sensation seeking, coping style, and negative emotion. Strong empirical support for this model was demonstrated in cross-sectional samples of both adolescents and adults; enhancement motives and coping motives were associated with alcohol use, and each was linked to distinct emotion and expectancy antecedents. Furthermore, enhancement motives mediated the associations of sensation seeking and enhancement expectancies with alcohol involvement, and coping motives mediated the associations of negative emotion and tension reduction expectancies with alcohol involvement. Coping motives for alcohol consumption are presumed to operate on the principle of negative reinforcement and involve drinking to ameliorate negative emotions or to make

25 such emotions more tolerable (Abrams & Niaura, 1987; Cooper, Russell, Skinner, Frone, & Mudar, 1992; Farber, Khavari, & Douglass, 1980). Several studies of coping motives and alcohol involvement in college samples have suggested that drinking to cope is a particular risk factor for alcohol problems (Carey & Correia, 1997; Kassel et al., 2000; MacLean, Collins, Morsheimer, & Koutsky, 1999).However, some evidence suggests that coping motives may affect alcohol misuse less strongly in drinkers for whom heavy alcohol use is more normative (i.e., older adolescents or college students; Bradizza et al., 1999; Perkins, 1999). MANAGEMENT PLAN Psycho education Supportive Therapy Behavior Therapy Cognitive Therapy Family Therapy

Short Term Goals Supportive work to be done to develop rapport and trust in patient. Psycho education to be done to his help the patient to understand the nature causes of illness, mode of treatment and his cooperative attitude in treatment. Relaxation techniques to be taught help him to overcome his angry feelings, calm down and to respond appropriately to angry feelings when they occur. Assertive training to be done to teach him to express his angry feelings in a direct and non confrontational manner. Activity scheduling to be used to provide him structured and organized day by developing purposeful activities. Cost benefits analysis to be used to enhance his awareness about the advantages and disadvantages of drug use.

26 ABC model to be taught to explain the client his way of thinking and its emotional behavioral consequences. Disputing to be used to help him to identify and debate his rigid and inflexible beliefs regarding drug addiction. Rational coping statements and encouraging phrases consistent with social reality to be used to reinforce the idea for him. Self management skills to be taught to enable him to modify his own life in relation to substance use. Mastery pleasure technique to be used to give him a sense of achievement by scheduling potentially, pleasurable and purposeful activities. Problem solving skills to be taught to deal with his problems positively rather than depending on drugs. Distraction techniques to be used to reduce craving. Assisting the client in restructuring his irrational beliefs by reviewing reality based evidence and misinterpretation. Long Term Goals Regular follow up sessions. To decrease overall intensity and frequency of angry feelings and to increase se the ability to recognize and appropriately express angry feelings as they occur. To come to an awareness and acceptance of angry feeling while developing better control and more serenity. To become capable of handling angry feelings in constructive ways that enhances daily functioning. Establish firm individual self-boundaries and improved self worth.

27 Break away permanently from any abusive relationship. To decrease the present conflicts parents and siblings while beginning to let go or resolving past conflicts with them. To achieve reasonable level of family connectedness and harmony where numbers support, help and concerned for each other. To accept responsibility for own behavior and keep behavior with in the acceptable limits of the rules of society. To develop and demonstrate a healthy sense of respect for suicidal norms, the rights for others and need for honesty. To improve method of relating to the world especially authority figures, behave realistic, less defiant and more socially sensitive. To maintain consistent employment and demonstrate financial and emotional responsibility. To increase goal directed behaviors. To focus thoughts on reality.

Therapeutic Techniques to Obtain Short Term Goals There are following therapies which will help in the treatment of the client Psychoeducation Psychoeducation can be beneficial in the treatment of patients who take drugs and alcohol (Tracey, 2005). Psychoeducation was first developed by Brain E. Tomlinson in 1962. Psychoeducation refers to the education offered to people who live with the psychological disturbance. It takes place in one-on-one discussion or in groups by any qualified health educator as well as health professionals. It consists of giving patients and other relatives adequate knowledge about disorder and teaching illness self management skills so that people have a better understanding of their of their illness and its treatment. There are several steps involved in psychoeducation. It involves first level partial

28 objectives and second level partial objectives. At first level (elemental mechanisms), patient and his family is educated and given awareness about disorder, early detections of warning symptoms and adherence with treatment. At second level (secondary mechanisms), the patient and family is educated about controlling stress, achieving regularity in life style and preventing suicidal behavior. At third level, patient and family is asked to improve social and interpersonal activity between episodes and increasing well being and improving the quality of life. Psychoeducation will be beneficial for the client by learning about the symptoms of drug addiction, expected time course, triggers of symptoms and treatment strategies. It will help him and his family to know about the causes of the problems solving skills to better assist the client and his family in dealing with possible manifestations of the illness and thus promote improved outcome. Supportive Therapy Supportive psychotherapy is an eclectic approach that integrates psychodynamic and cognitive-behavioral model and techniques. It is a dyadic treatment characterized by use of direct measures to ameliorate symptoms and to maintain, restore or improve self esteem, adaptive skills and psychological functions (Tracey, 2005). It will beneficial for the client by reinforcing the patients healthy and adaptive patterns of thought behaviors in order to reduce the conflicts. It will be beneficial for the client especially in the interpersonal context. Behavioral Therapies Behavioral therapy will be beneficial for the client as it aims to identify and change aspects of behavior that may be implicated in the cause and maintenance of drug addiction. It includes aversion therapy, covert sensitization, activity scheduling, pleasure and mastery technique, assertive training, problem solving skill and reinforcement. Aversion Therapy

Aversion therapy will be beneficial for the client by repeatedly presenting him with unpleasant stimuli while performing undesirable behaviors. After repeated pairings, the client is expected to react negatively to the substance itself and to lose his craving for it.

29 The client can be shocked or made nauseas while looking and reaching for a drug. The unpleasant feelings or sensations will become associated with that behavior (Turner, Calhoun, & Adams, 1987). It will be beneficial; for the client. Covert Sensitization

Covert sensitization can be used for the client and in this therapy the target behaviors and aversive stimulus are associated completely in imagination (Turner, Calhoun, & Adams, 1987). It will require the client to imagine extremely upsetting, repulsive and frightening scenes when he is taking drug. Contingency Management Therapy

A contingency contract is a written agreement between a client and one or other people that specifies the relationship between a target behavior and its consequences (Turne, Calhoun, & Adams, 1987). It will be beneficial for him by encouraging positive behavior change such as abstinence by providing punitive measures when engaged in undesirable behavior. Motivational Enhancement Therapy

Motivational Enhancement Therapy s designed to produce rapid, internally motivated change this treatment strategy does not attempt to guide and train the client step by step through recovery but instead employs motivational strategies to mobilize clients own resources. It will beneficial for the client by enhancing his motivation level to change his condition. Twelve Steps Paradigm

There are twelve steps that are developed for addiction. The idea of a twelve steps group is that each of the member rows to believe and then live through deeds each of the twelve steps. We admitted we were powerless over alcohol in that our lives had become unmanageable.

30 Came to believe that a power greater than our selves could restore us to sanity. Made a decision to turn our will and our lives over to the care of God as we understood him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves our wrongs Were entirely ready to have God remove all of these defects of character. Humbly asked him to remove our shortcomings. Made a list of all persons we had harmed and became willing to make amends to them all. Made direct amends to such people wherever possible except when doing so would injure them or others. Continued to take moral inventory and when we are wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs (Finley, 2004). and to another human being the exact nature of

Activity Scheduling

Activity schedule can be used to keep precise and accurate record of the clients activity so that frequency of all the behaviors is fare duly recorded. Those behaviors that need change/ modification can systematically taper off by exchanging them with desirable ones (Ellis & Dryden, 1997).

31

Assertive Training

It can be helpful for the client by increasing his ability to communicate effectively with people and being able to express needs and feelings in a direct and non confrontational manner. He will gain confidence and will share his feelings with others in order to clarify them and to gain insight as to causes. It will encourage the client in taking part in social activities. It will enhance his well being by learning how to meet others, talk to them, maintain eye contact, give and receive criticism, express feelings and improve his relationships with other people (Wykes, Tarriier & Lwis, 1998).. Behavioral Self Control

The client can be taught ways to resist craving in situation where drug is available. In learning to resist social pressure to take drugs, relaxation training and stress management training along with bio feedback and a better diet can all help the client. Problem Solving Skills

Problem solving therapy was originally developed by Zurilla and Goldfried. Problem solving refers to a systematic process by which a person generates a variety of potentially effective solutions to a problem, judiciously chooses the best of these solutions and then implements and evaluates the chosen solution. Problem solving technique serves a dual purpose by treating the immediate problems for which the client seeks treatment and preparing the client to deal on their own future problems and it teaches problem solving skills as a general coping strategy for dealing with problems that arise in course of daily life. The basic stages of problem solving therapy include adopting a problem solving orientation, defining the problem and setting goals, generating alternative solutions, deciding on the best solution implementing the solution and evaluating its effect. In early stages, the therapist may employ cognitive modeling to demonstrate the problem solving process. During the third stage, the therapist prompts the client is facilitated with

32 behavior therapy procedures ( Wykes, Tarrier, & Lewis, 1998). It will be beneficial for the client by teaching him how to deal with problems in life effectively. Progressive Muscle Relaxation Technique

Progressive muscle relaxation is a technique for reducing anxiety by altering tensing and relaxing. It will be useful for the client by reducing anxiety by alternately tensing and relaxing muscles. The client may start by sitting or lying down in a comfortable position. With the eyes closed, the muscles are tensed (10 seconds) and relaxed (20 seconds) sequentially through various parts of the body. The whole PMR session takes approximately 30 minutes ( Wykes, Tarrier, & Lewis, 1998). It will be beneficial for the client. Social Skills Training

Social skills training are another technique that has its origin in social learning theory ( Bellack & Muen, 1994). It helps in decreasing symptoms and increases the adjustments. The problems that can be targeted with this are the interpersonal inappropriate communication patterns, socially inept behaviors and problems forming close interpersonal relationships. In social skills training, the client can be taught conversational skills , gestures, eye contact, balanced voice tone (as the client is a stammered), and improved in notion. The client lacks this skills to an extent that he has cold relationship with father and eldest brother. Thus, by means of role-playing and role rehearsal, he can be trained in how to behave effectively in frustrating, distressing and threatening situations. Cognitive Therapies Cognitive therapy will be beneficial for the client by altering maladaptive thought patterns. It will help him to identify and correct his distorted and negatively biased thoughts. It will encourage him to reframe the way he thinks about life, to be able to bounce back from failures more effectively and to recognize and take credit for the good

33 things in his life. He will think that he has control over what happens to him. It includes rational emotive behavioral therapy. Rational Emotive Behavior Therapy

Rational emotive behavior therapy is a comprehensive, philosophically and empirically developed by Albert Ellis based psychotherapy which focuses on resolving emotional and behavioral problems and disturbances and enables people to lead happier and more fulfilling lives. It can be useful for the client by giving him awareness that behaviors and emotions are the result of what the person thinks about himself. It includes Disputing

Disputing is an active approach developed by Albert Ellis for helping clients to evaluate the helpfulness and efficacy of elements of their belief system (Dryden, 2003). It allows the patients to identify, debate, and ultimately replace their rigid, inflexible beliefs which are generally getting them into trouble. Disputing can be at four levels including functional, empirical, logical and philosophical disputing. Functional disputing is used to question the practical application of the patients belief and their accompanying emotions and behaviors. The therapist systematically shows client how much they potentially have to gain from working at replacing the irrational beliefs with their more flexible and realistic rational beliefs. Empirical disputing is used to evaluate the factual components of the clien ts beliefs and to test the specific beliefs are consistent with social reality or not. The task with an empirical dispute is to help the client to understand that he has been holding onto a belief which is insupportable and when questioned does not make sense, logical disputing is focused on questioning the illogical leap the client is making from desires or preferences to demands in his irrational thinking. Philosophical disputing address a life satisfaction issue. It will help the client in evaluating the helpfulness and efficacy of his belief system and to change his irrational beliefs. Rational Coping Statements

34 Rational coping statements are self statements which usually are implemented after forceful disputing has been accomplished but can also be used while the client is in the process of exploring his irrational beliefs. These factual, encouraging phrases are consistent with social reality and clients are encouraged to repeat them consistently to reinforce idea for them (Dryden, 20033). It can be used for the betterment of the client. It will help the client to repeat coping statements to reinforce idea for him. Relapse Prevention

Relapse prevention is a systematic method for teaching recovering patients to recognize and manage warning signs. It will be beneficial for the client by reviewing potentially provocative thoughts and experiences which may contribute to relapse impulses, by brainstorming solutions with the client for problematic situations (Ellis & Dryden, 1997). Referenting

Refrenting can be executed to get the client rid of the chain smoking (including tobacco and charas-cannabis). The client can be asked to write down the positives and negatives or pros and cons of this habit and then choose what should be adopted or not by taking the decision (By Joseph Danish) Cognitive Behavioral Therapy

CBT was developed by Aaron T Beck and is psychotherapeutic technique that aims to solve problems regarding dysfunctional emotions, and cognitions through a goal oriented systematic procedure. It includes Double Column Technique

Recoding cognitions and responses in parallel columns is a way to begin examining, evaluating and modifying the cognitions. The patient is instructed to write his cognitions. The patient is instructed to write his cognitions in one column and then write a reasonable response to the cognitions in the next column. The written assignment may also include

35 additional columns for describing the patients affect and behavior and the specific description of the situation or event which preceded the cognition. Thus depending on the number of columns used the technique may be referred to as the double column, triple column and even the quadruple column. The rationale for the approach is to teach the patient more precise discriminations of his emotions and thoughts. The therapists major task is to help the patient think of reasonable response to the negative cognitions. The therapists goal is to increase the patients objectively about his cognitions and unpleasant affect unproductive behavior (Beck, Wright, Newmsn, & Liese, 1993). It will be beneficial for the client and he will begin examine, evaluate and modify his maladaptive cognitions. Downward Arrow Technique

The downward arrow technique is used to identify intermediate beliefs. The therapist identifies a key automatic thought which he suspects directly stemming from a dysfunctional belief then he ask the patent meaning of the cognition assuming the automatic thoughts were true. He continues to do so until he has uncovered one or more important beliefs. Asking what a thought means to the patient often elicits an intermediate belief and usually uncovers the core belief (Beck, 1195). It will be beneficial for the client in order to find out a core belief. Specific Techniques for Craving There are some techniques used to reduce the aroused cravings and it includes: Distraction technique Flashcards Imagery technique Rational responding to urge related automatic thoughts

Distraction Technique

36 The key goal of distraction techniques is to get patients to change their focus of attention from internal such as automatic thoughts, memories and physical sensation to external. These techniques are quite simple but they help to diminish cravings. There ere some steps involved: 1) Instruct patients to concentrate their attention on describe surroundings. The more they can focus and give details about external events, the more likely they are to focus less on the internal cravings. 2) Talking can also b used as distraction and this involves starting a conversation with a friend, relative or to the therapist. 3) Patients can remove themselves from the cue laden environment. 4) Perform household chores as a positive distraction. This goal directed activity not only diminish their cravings but also enhances self esteem. 5) Encourage patient to recite a favorite poem or prayer (Beck, Wright, Neqwman, & Liese, 1993). It will be beneficial for the client in reducing his cravings. Flashcards When cravings are strong patients seem to lose the ability to reason objectively. Generating coping statements can be helpful in getting patients through this critical period. The usefulness of the coping statements can be enhanced by asking patients to write these statements on flashcards (3*5 index cards). The statements include d are You feel more sane you do not use. You look good physically, keep it that way. (Beck, Wright, Newmwn & Leises, 1993).it will be beneficial for the client. Imagery Techniques Imagery techniques can be useful in the reduction of craving and these include image refocusing, negative image replacement, positive image replacement, image rehearsal and image mastery. Refocusing is essentially a distraction technique. Patients direct their attention away from internal cravings by imaging external events. Refocusing can begin first by saying stop. Another imagery technique is negative image replacement. It is helpful for patients to substitute a negative image regarding the many unfortunate consequences of taking the drug such as feeling helpless and hopeless. This image will be strong enough to dissuade them from taking the first drink. Positive image replacement is a related technique to help cope with cravings and urges the patients imagined themselves

37 in a positive state such as going back to work and to normal routine. This may diminish cravings. Imagery rehhearsel should be used when patients are going to be in cue laden situation (Beck, Wright, Newman, & Lieese, 1993). It will be useful in the reduction of the craving of the client. Rational Responding to Urge-Related Automatic Thoughts Therapists start by training patients to self monitor automatic thoughts when they are having unpleasant emotions such as anger, anxiety, sadness or boredom. Later the patients are instructed how to assess their automatic thoughts while experiencing cravings and urges. It is helpful to have patients carry a therapy notepad and a pen in order to write down these thoughts. Patients are told that any time they experience strong cravings or unpleasant emotions they should ask questions to him self. They are instructed to note any physiological distress and then write down their answers. The daily method is used to help patients (Beck, Wright, Newman, & Liese, 1993)). It will be beneficial for the client to diminish his cravings. Family Therapy Family therapy usually involves the whole family. The aim is to educate and make them aware of the state of the client, to clarify any misconception related to the problem and to guide the whole family in how to resolve the conflicts in healthy way. In the current case, the client has so many problems regarding the family and home life. His father has a very complaining attitude towards the client. The clients parents and siblings can be involved in the rehabilitation process of the client. They can be educated about the nature of his problem and how they can build an understanding and warm relationship with him to win his trust and warmth. SUGGESTIONS AND LIMITATIONS There should be an increased number of sessions to get detailed information about the client. Environment should be adequate enough to get full attention of the client. The family should be educated to treat him with love and affection.

38 Helping him to learn that sharing and feelings and emotions really help him in alternating memories about stressful life events. Family can play an important role in altering the clients behavior doing things are in mood consequence with the client. There were some limitations that were observed There was limited number of sessions. Environment was not adequate and it was difficult to gain full attention of the client. Client was aggressive and become angry over small things. The information was reluctant in giving information about the client.

References: . American Psychological Association. (2000). Diagnostic and statistic Manual of Mental Bandura, A. Social Learning Theory, Upper Saddle River, NJ: Prentice Hall, 1977.

39 Britt, D. W., & Campbell, E. Q. (1977). A longitudinal analysis of alcohol use, environmental conduciveness and normative structure. Journal of Chou SP, Pickering RP: Early onset of drinking as a risk factor for lifetime alcoholrelated problems. Br J Addict 1992; 87: Cloninger, C.R., & Begleiter, H., eds. Genetics and Biology of Alcoholism: Banbury Report 33. New York: Cold Spring Harbor Laboratory Press, 1990. Cotton, N.S. The familial incidence of alcoholism: A review. Journal of Studies on Alcohol 40:89-116, 1979. Disorders-Text Revision. (4th ed.). APA: Washington, D.C Ellickson, P.L. and hays, R.D. Antecedents of drinking among young adolescents with different alcohol use histories. J. Stud. Alcohol 52: 398-408, 1991. Fitzgerald, H. E., & Zucker, R. A. (1995). Socioeconomic status and alcoholism: The contextual structure of developmental pathways to addiction. In H. E. Fitzgerald & B.M. Lester (Eds.), Children of poverty: Research, health, and policy issues (pp. 125148). New York: Garland Goldman, D., & Linnoila, M. Genetic approaches to alcoholism. Progress in NeuroPsychopharmacology and Biological Psychiatry 10:237-242, 1986. Goodwin, D.W.; Schulsinger, F.; Moller, N.; Hermansen, L.; Winokur, G.; & Guze, S.B. Drinking problems in adopted and nonadopted sons of alcoholics. Archives of General Psychiatry 31:164-169, 1974.

40 Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity.Arch Pediatr Adolesc Med. 2006 Jul;160(7):73946.Institute on Drug Abuse, 2007. Hrubec, Z., & Omenn, G.S. Evidence of genetic predisposition to alcoholic cirrhosis and psychosis: Twin concordances for alcoholism and its biological endpoints by zygosity among male veterans. Alcoholism: Clinical and Experimental Research 5:207-212, 1981. Johnston, I.D., Omalley, P.M., Bachman,J.G., and Schulenberg, J.E. Johnston, L.D., et al. National Survey Results on Drug Use From the Monitoring the Future Study, 1975-1994: Volume I. Secondary School Students. Rockville, MD: National Institute on Drug Abuse, 1995. Kandel, D.B. and Andrews, K. Processes of adolescent socialization by parents and peers. Int. J. Addict. 22: 319-342, 1987. McGue, M. "Genes, Environment, and the Etiology of Alcoholism." Paper presented at the Working Group on the Development of Alcohol-Related Problems in HighRisk Youth conference, Washington, DC, Nov. 14-16, 1991. Monitoring the Future: National Survey Results on Drug Use, 1975- 2006, Vol. 1, NIH Publicati on No. 07-6205, Bethesda, MD: National Pickens, R.W., & Svikis, D.S. Genetic influences in human substance abuse. Journal of Addictive Diseases 10:205-214, 1991.

41 Pickens, R.W., & Svikis, D.S. The twin method in the study of vulnerability to drug abuse. In: Pickens, R.W., and Svikis, D.S., eds. Biological Vulnerability to Drug Abuse. National Institute on Drug Abuse Research Monograph Series No. 89. DHHS Pub. No. (ADM)88-1590. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 41-51. Robins, G., Elliott, P., & Pattison, P. (2001). Network models for social selection processes. Social Networks, 23, 130. Roe, A. The adult adjustment of children of alcoholic parents raised in foster homes. Quarterly Journal of Studies on Alcohol 5:378-393, 1944. Studies on Alcohol, 38, 16401647.