PSYCHOTHERAPY REPORT

Department of Clinical Psychology

Faculty of Behavioral and Social Sciences
SGT University, Gurugram, Delhi-NCR

CR No.- 100562879
Name- K.J. Occupation- Student
Age- 20 years Gender- Female
Religion- Hindu Education- B.A. Nursing
Marital Status- Unmarried Language Spoken- English, Hindi
Socio-Economic Status- Middle Residence- Sagarpur

Referred by: Psychiatry Department

Reason for Referral: For psychotherapeutic intervention
Source of Information- The information was obtained from the patient.
Reliability of Information- The information is reliable and partially adequate.

Chief Complaints
“Hyperactive rehti hu aur attention mein dikkat hoti hai”
“Apne emotions control mein nahi rehte”
10 years
“kabhi ek dum se low feel karti hu phir achanak theek hp jati hu”
“Feel extensive sexual urge””

“Bodyache rehta hai, nausea and loose motions hai”

“Feel stressed, anxious and fearful, so nahi pa rahi hu”
Palpitations hoti hai, I am unable to relax my body, keep fidgeting” 2 months

“I have no one to look up to, koi nahi Samantha mujhe”

Informant: Unavailable
Onset: Insidious
Course: Fluctuating
Progress: Deteriorating

Predisposing Factors- authoritarian parenting, rigid beliefs of parents, uncongenial family

environment
Precipitating Factors- bullied by classmates and conflict with college management
Perpetuating Factors- lack of social support and excessive stress at home and constant
issues with girl friend

History of Present Illness

Patient was maintaining optimally well until childhood. In 2 nd standard she got involved with
a boy and thought her pleasure point shifted to genitals but when she saw a boy in her
classroom inserted pencil inside a girl’s vagina, she was traumatized by it. Later she passed
her 3rd, 4th, 5th standard. In 6th Standard she suddenly expected an intense feeling of
empowerment wherein she could do anything without any reason. She resented her class
teacher for forcing her to sit next to a boy who stole pens. This led to falling grades which
resulted in increasing complaints about her academic and behavioural issues. Patient reported
that when she was in 7th grade her teacher had told that she was unrecognizable which caused
stress and guilt inside the patient.
Its during her time in 8th standard the patient reported feelings of numbness, emptiness and
heaviness in her head. She had run other unpleasant experience at the time when a teacher hit
her and the patient ran out of the classroom. In 9 th standard the patient reported about her
attention-seeking behaviour and how she considered herself useless. This led to multiple
interpersonal conflicts in the school during which time the patient reported her school
principal had hit her and this incident led her to first self-harm behaviour which included
cutting her thumb with blade everyday. Patient told her teacher about her situation who then
involved patient’s parents, this led to meeting between school authority and the parents. Upon
seeing her parents sitting in principal’s office the patient reported having an anxiety attack.
Later the patient made several attempts to convince her teachers and parents, “main bahane
nahi bna rahi thi padhai se bachne ke liye” however upon realising that nobody understood
her situation she eventually gave up explaining herself. Patient reported performing poorly in
her board exams which upset her and she cut her hair. The patient was taken to a psychiatrist
who hugged her inappropriately and told her that cutting hair was an abnormal behaviour.
This was another traumatic experience for the patient. During summer vacations that year the
patient went to a mediation centre where she got physically involved with another girl which
according to her confirmed her sexual orientation. She always wanted to be with a girl.
In 11th standard the patient decided to go to Punjab for further studies which emotionally hurt
her mother and watching her mother cry the patient felt guilt and stressed. She opted for
Psychology however upon being pressurised by parents the patient switched to Nursing
course at SGT University. Here the patient met another girl and their romantic relationship
developed intensely. Patient reported that her partner was overly possessive about the patient
and always kept a check on her whereabouts. Most of the days they would end up fighting a
leaving the patient with experiences of autonomic symptoms like palpitations, sweating and
body aches, “when I am with her, I feel anxious and sacred”, and the patient reported
feeling claustrophobic in this relationship. However, the patient also confessed that the
patient’s partner took very good care of her.
Lately at the college the patient reported being often bullied by a group of classmates owing
to her sexual orientation and appearance, “I feel scared”, The boys sent her messages on the
phone threatening to hurt her and also made derogatory remarks at her while she was with
other students and faculty in the bus. She got into a conflict with the dean while reporting the
incident as she felt that the dean was treating her unfairly as he did not seem take a rightful
action against her bully inspite of her reporting the matter. Now she regrets her impulsive
behaviour which furthermore worsened her situation, “main so nahi pati hu aur boot
bodyache rehta hai”.
The patient is now extremely anxious and stressed as she fears being rusticated from the
university. All of this led to her inability to sleep, loss of appetite, intense anxiety,
palpitations, sweating, upset stomach and body aches. She is not able to manage her emotions
which is creating new problems for her with other people around her including her friends,
“koi nahi samanjhta mujhe, I have no one to look up to”. She fears that when her family
discovers the matter, they would not understand her or support her instead they would blame
her for everything. These thoughts are making it difficult for the patient for function
optimally. She reported lack of sleep for the past many days and therefore she visited SGT
hospital to get her medications reviewed at the department of psychiatry following her visit at
the department of Clinical Psychology where she plans to restart her therapy.

Negative History
No history of suggestive of seizures, significant head injury, and loss of consciousness.
No history suggestive of harmful use of any psychoactive substance.
No history suggestive of hearing voices, seeing things, people putting thoughts into patient’s
mind or anybody being able to hear what patient is thinking.
No history of suggestive of elated mood, inflated self-esteem, increased energy, over
talkativeness.
No history suggestive of intense fear of specific object/situation
No history suggestive of intrusive repetitive thoughts, images, impulses or any repetitive
behaviour.

Treatment History
Medical History: Patient reported sinus and tendinitis on her right shoulder which often
makes it difficult for her to sleep.
Psychiatric History: Patient reported she took medications in her childhood due to self harm
from a neurology centre but has misplaced the prescription.
In 2022, she visited RML Hospital where she was prescribed medication for anxiety and
insomnia.
In January 2023 she visited SGT Hospital to get her medications reviewed.
Current Medication: Escitalopram (10 mg) + Lorazepam (0.25mg) + Maltroz (3 mg)

History of Past illness

Medical Illness- Patient reported a history of tendinitis and sinusitis for the past 4 years. The
conditions caused stress and the patient often have sleep issues due to the unbearable pain.
She suffered an injury which caused inflammation that causes pain. The patient is in
painkillers and some time also takes physiotherapy sessions when the pain aggravates.
Psychiatric Illness-
In 8th grade the patient had attempted to self-harm by making cuts on her thumb with a blade.
She resorted to this behaviour after she was hit by the principal in the classroom. The patient
was enduring overwhelming emotional and interpersonal challenges in her class with other
students. She was experiencing a lot of stress due to her inability to resolve her situation. She
was scared to approach her parents for support as she knew they would turn everything
against her increasing her challenges and stress. She resorted to maladaptive coping
mechanism like self-harm to reduce anxiety caused by her overwhelming emotions. He
inability to manage and regulate her emotions often put her in conflicting interpersonal
situations. Her grades began to fall, and her behaviour began to deviate which increased her
problems to a point wherein the principal had to intervene, and she was slapped in the
classroom. Later in 2022, the patient went through a break-up which was difficult for her to
endure causing her intense anxiety, restlessness, lack of sleep and bodyaches. She was
depressed including reduced energy and lack of motivation for activities. At this time her
mother took her to RML hospital for medical intervention where she was pre3scribed
medication for sleep, anxiety and depression.
In 2023, the patient visited Psychiatry department at the SGT Hospital for review of her
medication prescribed at the RML Hospital. She was experiencing intense anxiety which
included autonomic symptoms (palpitations, sweating, body aches, loose motions, rashes on
skin, burning eyes). She also struggled to sleep for nights together partially owing to her
tendinitis on her right shoulder. These symptoms relapsed due to major conflicts between her
and her partner who was also under psychiatric medications at the time and simultaneously
with her mother as well. Her medicines were reviewed and prescribed.
In April 2024, the patient revisited Clinical Psychology department of SGT Hospital to restart
her therapy sessions and to review her medications. She reported intense anxiety including
autonomic bodily symptoms, irritability, mood swings, inability to sleep for past few days
owing to her conflicts at the college with her classmates which led to conflicts with
authorities in the college. She fears getting rusticated which could create further issues for her
back home. While she wished her parents could understand her and support, she feared they
would blame her and corner her due to the situation she was in.

Family History of Medical Illness- According to the patient, her father died at the age of 27
years. He was in paralytic condition. He died due to cardiac arrest.
Family History of Psychiatric Illness- Father has depression and mother is aggressive and
violent.
Family Genogram

Personal History
Birth and developmental History- Could not be elicited due to unavailability of the
informant.
Childhood History- Patient reported that she was an anxious and a hyperactive child with
feelings of emptiness, fears and confusion. She experienced attention problems which
impacted her academic performance. The patient had an impulsive behaviour mostly leading
her to conflicts and issues in her interpersonal relationships. She mostly got into trouble with
school authority owing to her impulsive behaviour. She was struggling to understand her
sexual orientation at this stage as she felt a liking towards girls.
Home Environment- Patient reported that in childhood the environment at home was hostile
because there were issues between her parents. Her mother’s aggressive behaviour caused a
lot of conflicts at home. There were issues between her mother and grandmother which
created fights at home. The family lacked cohesion. She reported that she felt close to her
younger brother and elder sister.
Scholastic and extracurricular activities- Patient started school at the age of 3 years and
studied in co-ed school. She completed her 12 th from CBSE Punjab. Patient reported that she
has been an average student at school and used to enthusiastically participated in
extracurricular activities. She had disciplinary issues in the school and also sometimes got
into conflicts with the school authority. She has earned 18 olympiads, used to play national
level sports and has many trophies to her name. She was also good in abacus.
College History- Patient reported that she joined SGT university because her mother insisted
her to take up Nursing. She reported having anger issues and impulsivity which would often
put her in conflictual situations with the HoD. She reported mostly feeling lonely and
emotionally weak during her time in college. She reported being bullied by her male
classmates about her sexual orientation and appearance. The patient reported that college
environment is not conducive for her mental health.
Occupational History- N/A
Sexual and Marital History- The patient attained menarche at the age of 13 and has had a
regular menstrual cycle. The patient gained sexual knowledge while she was in UKG. She
reported masturbating when she was in 7 th grade and has sexual urges including intercourse,
masturbation and sexual fantasies about women.
Legal History- Nil contributory
General Pattern of Living- The patient reported initial weeks of joining SGT University as
one of the best periods of her life, she met her girl friend there. She reported her partner
would take good care of her which made the patient dependent on her partner for every little
thing pertaining to chores and daily activities. However, during adversities the patient tends
to blame others for her problems.

Premorbid Personality
Social relations: The patient has always been an extrovert. She can easily make friends and
is comfortable talking to strangers. However, she is not tolerable of criticisms and feedback.
She prefers company over solitude.
Character: The patient reported to have low self-esteem and negative attitude towards self.
She reported being in hostile relationships. She reported not being responsible and doesn’t
believe in moral standards. She reported her academic capabilities as her strength
Attitude: Patient reported mostly having a negative attitude towards self and others. She is
mistrustful about other’s intentions. She describes herself as being a highly impulsive, short-
tempered and emotional person.
Hobbies and use of leisure time: The patient like to masturbate during leisure time.
Predominant mood: Dysphoric.
Habit and dependence: Masturbating
Impression: Maladjusted pre-morbid personality

Mental Status Examination

Appearance
General appearance: A well-kempt female with endomorphic body built, appearing to be of
the stated age walked into the OPD room. She was in touch with the surroundings.
Attitude towards the examiner: She greeted the examiner and was cooperative during the
session. Eye contact was made and maintained. Rapport could be established with ease.
Psychomotor activity: Patient was restless and continuously fidgeting throughout the
session. She kept changing her sitting position in the chair. She was sweating profusely and
kept cleaning her forehead. Her eyebrows were furrowed upwards appearing to be in
discomfort and pain.
Speech
Her speech was audible, in response to questions asked, with normal reaction time, adequate
productivity, coherent, circumstantial, with normal pitch, tone and volume.
Higher Mental Functions
Attention and Concentration
Digit forward-5/6
Digit Backward-3/6
Serial Subtraction- (100-7): 100, 93, 89, 75, 72, 66, 59.
Impression: Attention could be aroused but could not be sustained.
Orientation
Time: 11 am
Place: SGT Hospital
Person: Psychologist
Passage of time: “30-50 minutes”.
Impression: Oriented to TPP.
Memory
Immediate Memory: Table, fan, window, pen, wall
Recent Memory: What did you have in breakfast? “Nothing”
With whom have you come? “I came alone.”
Where were you before the hospital? “I was at the College”
Remote Memory: Birthplace? Delhi
At what age did you start going to school? “At the age of 4”
Impression: Intact immediate, recent and remote memory.
Abstract Thinking
Similarity:
Apple and Mango- “Both are fruits and sweet”
Table and Chair- “Used for working, both are wooden”
Milk and medicine- “Both cure illness”
Poem and novel- “Both are read, both are teaching lessons of life”
Pen and Pencil- “Both are long.”
Difference:
Apple and Mango- “Shape and color”
Table and Chair- “We do work on the table and we sit on the chair”
Milk and medicine- “milk is white in color but medicines can be of any color. Also,
medicines can be harmful sometimes, they have side-effects on our body.”
Poem and novel- “Poem rhymes but novel don’t. Poems would be shorter in comparison to a
novel”
Pen and Pencil- “Pencil is wooden, and pen is plastic”
Proverb:
An apple a day keeps a doctor away- “Eating an apple a day will keep you healthy”
Action speaks louder than the words- “Action is a better reflection of one’s character than
words”
A happy heart is better than the full purse- “Happiness is better than money”
A Jack of all trades is master of none: “A person with some knowledge of several fields can’t
be a master in any of them.”
All is well that ends well- “As long as the outcome is good, problems on the way don’t
matter”
Impression: Thinking present at abstract level.
Intelligence
General fund of Information:
Capital of India? “Delhi”
Prime Minister? “Narendra Modi”
National Anthem? “By Rabindranath Tagore”
5 rivers? “Ganga, Yamuna, Narmada, Godavari”
Indian Courts? “Supreme, High court”
Independence Day? “15th Aug 1947”
Simple and Complex: Simple items were answered correctly but couldn’t answer complex
ones.
Impression: Average Intellectual Capacity.
Affect
Subjective: “irritated and scared”
Objective: Dysphoric, full/broad range, normal reactivity, communicable.
Thought
No disturbance elicited in thought flow/ stream, form and possession. Thought content
reflected worry (I don’t know what action Dean will take?), inflated self-esteem (The Dean
doesn’t know how to do his job right), depressive cognition (I can’t do anything right, I
always get into conflicts with authority even if its not my fault) and somatic symptoms
(tendinitis, bodyache, loose motions, palpitations).
Perceptual disturbances
No disturbance elicited in Perception.
Judgement
Personal judgment: What will you do after getting better?
“I will focus on my studies and work on my relationships.”
Social Judgement: Frequent fight with mother, friends, and faculties.
Test judgment:
Fire situation: “I will get out of the house first and then I will call fire brigade”
Envelope situation: “I will try to deliver it to the address”
Rain situation: “I will use the umbrella”
Impression: The personal and test judgement is intact. However, the social judgement is
impaired.
Insight
Q: Do you think that what is bothering you is part of an illness?
A: “Yes, I know I have impulsivity issues but I also think people do not understand me,
and I am not able to do anything about it‟

Q: What problem you feel this could be?

A: “I feel I am abnormal”
Q: What might be the cause of this problem?
A: “It could be my hair style, sexual orientation that people including my family is not able to
accept.”
Q: Do you feel that therapy could be of any help?
A: “Let’s see”
Impression: Grade 3 Awareness that illness is due to external factors.

Diagnostic Formulation
Index patient A. 21 years old Hindu, unmarried female, of middle socioeconomic status, from
Haryana, presented with chief complains of anxiety, stress, autonomic symptoms, muscular
tension, fear, reduced energy, mood swings, and think more of worse with insidious onset,
fluctuating course and improving progress with predisposing factor of authoritarian
parenting, uncongenial family environment, precipitating factor bullying by male class mates
leading to conflicts with college authorities and perpetuating factor of lack of social support
and excessive stress at both hostel and classroom.
On MSE, a young female, well kempt, appropriately dressed and in touch with the
surroundings
having cooperative attitude towards the examiner and examination came to the OPD
unattended. Rapport could not be established with ease; eye contact was not made initially
but eventually maintained. Agitation was present. Speech was audible, in response to the
question asked with normal reaction time, was coherent, goal directed and circumstantial with
normal rate, tone and volume. Attention and was aroused but not sustained. She was oriented
to time, place and person. Patient had intact memory, adequate abstractedness and average
level of intelligence. Affect was anxious, was communicable and appropriate to the thought
content, with full range and normal reactivity. No disturbance in stream, form or possession
of thoughts were elicited. Thought content reflected anxiety, worry, and pessimistic view. No
perceptual disturbances were elicited. Test and personal judgement was intact but social
judgement was impaired with grade 3 level of insight.

Diagnosis
F41.1 Generalized Anxiety Disorder
F60.31 (Emotionally Unstable Personality Disorder) Borderline Type
Points in Favour: GAD
- Depressed mood
- Loss of interest in pleasurable activities
- Reduced energy
- Reduced attention and concentration
- Reduced self-esteem and confidence
- Ideas of guilt
- Disturbed sleep
- Disturbed appetite
- The current episode can be separated from the previous one by the duration of two
months.
Points in Favour: Borderline Type
 Impulsivity (multiple sexual partners and binge eating)
 A pattern of unstable and intense interpersonal relationships
 Unstable self-image (sexual orientation unclear until the age of 15 years)
 Chronic feelings of emptiness
 Pattern of instability in affect marked by anxiousness and dysphoria)
 Inappropriate intense anger
 Suicidal thoughts

Rationale for Testing

To confirm the diagnosis:
The patient has displayed manifestation of anxious mood and irritability along with inability
to
concentrate on everyday task and difficulty with interpersonal relationships. It is desirable to
understand his characteristic way of responding to environmental stressors and her coping
style.
To understand the personality and interpersonal relationships of the patient:
Psychopathology is invariably an extension of personality traits. To know the personality
structure of the patient which involves the dominant traits and response patterns used by the
patient in stressful circumstances, a personality test and also a projective test would help a
great deal. The patient’s manner of interaction with others and formation and maintenance of
interpersonal relationships are also important facets which will be revealed by these tests.
For assessment of assets and limitations of the client which will aid in preparing the
management plan.
Tests administered and their Rationale:
Bender Gestalt Test (BGT): To assess the visuospatial and motor skills to rule out
abnormalities in this area of cognition.
Draw a Person Test (DAPT): The test was administered as a means of understanding
patient’s self-concept, changes in attitude and mood.
Millon Clinical Multiaxial Inventory-III (MCMI-III): To understand the underlying
clinical
personality patterns of the patient and to assess the psychopathology for confirmation of
diagnosis.
Rorschach Psycho-diagnostics: The tool was administered as a tool for personality
assessment to analyse patient’s personality and understand his psychopathology. It also aids
in diagnostic clarification.
Sacks Sentence Completion Test (SSCT): The test was administered to assess patient’s
Family relations, sexual content, interpersonal relationships and self concept. This test
indicate attitude, beliefs, motivations and other mental states of the person.
Thematic Apperception Test (TAT): To assess the patient’s interpersonal relationships and
communication pattern with others. To identify the major needs, conflicts, press and ego
strength of the patient.
Rating Scales:
Hamilton Anxiety Rating Scale (HAM-A): To assess the baseline severity level of
symptoms
associated with anxiety.
Hamilton Depression Rating Scale (HAM-D): To assess the baseline severity level of
symptoms associated with depression.
General Behavioural Observation
The patient was cooperative towards the examiner during the testing procedure. The patient
did not face any difficulties in understanding instructions and performed the tests with
interest. She gave adequate responses and understood the importance of test findings for her
treatment.

Test Findings:
Eysenck Digit Span Test: Digit Forward: 5 & Digit Backward: 3
Bender Gestalt Test: Z score: 51 = No organicity was present.
Draw A Person Test - Indicate Poor judgement, primitive aggression, controlled behaviour,
tendency to intellectualise, indicate insecurity, regressive tendencies, feelings of inadequacy,
signs of withdrawal, sexually excited and rebellious tendencies.
Millon Clinical Multiaxial Inventory-III (MCMI) - 85 & above =
 2A - Avoidant- 102
She experiences few positive reinforcers from others, vigilant and always on guard, ready to
distance herself from anxious anticipation of life's painful or negatively reinforcing
experiences. Her adaptive strategy reflects fear and mistrust of others. She maintains a
constant vigil to prevent her impulses and their longing for affection from resulting in a
repetition of the pain and anguish to have experienced with others. Only by active withdrawal
she can they protect herself. Despite her desires to relate to others, she have learned that it is
best to deny these feelings and to keep a good measure of interpersonal distance.
 2B - Depressive - 99
She experiences pain as permanent. Pleasure is no longer even considered possible. The
evidence favouring a constitutional predisposition is strong, much of it favouring genetic
factors. The thresholds involved in permitting pleasure or sensitising one to sadness vary
appreciably. She is inclined to pessimism and a disheartened outlook. Similarly, experience
can condition a hopeless orientation to significant loss. A disconsolate family, a barren
environment, and hopeless prospects can all shape the depressive character style.
 3 - Dependent - 92
She has learned not only to turn to others for nurturance and security but to wait passively for
their leadership in providing them. She is characterised by a search for relationships in which
they can lean on others for affection, security, and guidance. She has lack of initiative and
autonomy is often a consequence of parental overprotection. As a function of these
experiences, she has simply learned the comforts of assuming a passive role in interpersonal
relations, accepting what kindness and support may find and willingly submitting to the
wishes of others in order to maintain their affection.

 6B - Sadistic - 87
She is an aggressive personality and is generally hostile and pervasively combative, and
appears to be indifferent to or pleased by the destructive consequences of their contentious,
abusive, and brutal behaviour. Although many cloaks their more malicious and power-
oriented tendencies in publicly approved roles and vocations, they give themselves away by
their dominating, antagonistic, and frequently persecutory actions.
 C - Borderline - 93
She has structural defects and experiences intense endogenous moods with recurring periods
of dejection and apathy, often interspersed with spells of anger, anxiety, or euphoria. She
have
recurring thoughts about self-mutilation, appear overly preoccupied with securing affection,
have difficulty maintaining a clear sense of identity, and display a cognitive affective
ambivalence that is evident in conflicting feelings of rage, love, and guilt toward others.
 P - Paranoid - 90
She displays vigilant mistrust on others and an edgy defensiveness against anticipated
criticism and deception. There is an abrasive irritability and a tendency to precipitate
exasperation and anger in others. She often expresses fear of losing independence, leading
them to vigorously resist external influence and control. She is distinctive in the immutability
of their feelings and the inflexibility of their thoughts.
 A - Anxiety- 95
She reports feeling either vaguely apprehensive or specifically phobic. She is typically tense,
indecisive, and restless and tends to complain of various types of physical discomfort, such as
tightness, excessive perspiration, ill-defined muscular aches, and nausea. She have a
generalised state of tension, manifested by an inability to relax, fidgety movements, and a
readiness to react and be easily startled. Somatic discomfort like, clammy hands or upset
stomach. Also notable are worrisomeness and an apprehensive sense that problems are
imminent, a hyper alertness to one's environment, edginess, and generalised touchiness.
 D - Dysthymia - 98
She remains involved in everyday life but have been preoccupied over a period of years with
feelings of discouragement or guilt, a lack of initiative, behavioural apathy, low self-esteem,
and frequently expressed futility and self-deprecatory comments. During periods of dejection,
she may be show tearfulness, a pessimistic outlook toward the future, social withdrawal, poor
appetite or overeating, chronic fatigue, poor concentration, a marked loss of interest in
pleasurable activities, and decreased effectiveness in performing routine life tasks.
 R - PTSD - 100
She has experienced an event that involved a threat to their life and reacted to it with intense
fear or feelings of helplessness. Images and emotions associated with the trauma persistently
result in distressing recollections and nightmares that reactivate the feelings generated by the
original event. Symptoms of anxious arousal (e.g., exaggerated startle response, hyper
vigilance) persist, and efforts are made to avoid circumstances associated with the trauma.
 CC - Major Depression - 107
She is incapable of functioning in a normal environment and depressed, and express a dread
of the future.and a sense of hopeless resignation. She displays an agitated quality, incessantly
pacing and bemoaning their sorry state. Several somatic problems often occur during these
periods, notably decreased appetite, fatigue, weight loss or gain. Insomnia, and early rising.
Problems of concentration are common as are feelings of worthlessness or guilt. Repetitive
fearfulness and brooding are frequently in evidence.
 8B - Masochistic - 93
She encourages others to exploit or take advantage of them. Focusing on her features, she
asserts that she deserves to be shamed and humbled. To compound her pain and anguish,
which she may experience as comforting, she actively and repetitively recalls her past
misfortunes and expect problematic outcomes from otherwise fortunate circumstances.
Typically acting in an unassuming and self-effacing way, they often intensify their deficits
and place themselves in an inferior light or abject position.
TAT - Thematic Apperception Test - TAT findings also indicate that the patient has poor
interpersonal relationships. Integration of ego strength is weak. Major needs elicited are need
for achievement, affiliation, acquisition, autonomy, abasement and nurturance. Major
Conflicts are achievement vs. acquisition, affiliation vs. abasement and nurturance vs.
succorance. Defence mechanisms prominently used are primitive idealisation, acting out and
externalisation.
Rorschach Ink Blot Test: RIBT - R: 37, L: 2.36, Afr= 0.48, CDI: 4, DEPI: 3, OBS: 1,
SCON: 6, Isolation Index: 0.40, Egocentricity index: 0.67, X+%= 0.40, X-%= 0.16, Xu%=
0.43, XA%= 0.83, WDA%= 0.78, P= 4, Zd= -0.5, W:M= 2:1, Adj D= -1, D= -1, EB= 1:1.
Domains of Rorschach test:
Control and Stress Tolerance
Person is in stable of chronic stimulus overload. A s a consequence, her control capacity and
ability to deal with stress effectively is less than might be expected, proclivity for
impulsiveness exists. Person is more vulnerable to control problems and disorganised under
stress.
Situationally Related Stressed
Overload state exists in which the individual is experiencing more internal demands that she
does not respond easily and effectively.
There is mild increase in psychological complexity because of stress condition and create
emotional confusion.
Affect
State of emotional disarray exist. She tends to flounder in social environment because
relations with others are superficial, tenuous and unrewarding. Thus, episodes of
disappointment, distress or even despair are common and emotional disarray during these
episodes is similar like in chronic depression. Emotions tend to change more often as their
support system strengthen or weaken. She has a ambient personality and does not show
consistency of either introversive or extra tensive style in decision making. They are
inconsistent and role played by their feelings varies considerably. She suppresses and have
constraint of emotion. She is less interested in emotional stimuli awareness of problems and
inclination to avoid situations that would exacerbate those difficulties. She controls and
modulate emotional discharge.
Information Processing
She has an Avoidant style, which indicate tendency to economise and avoid complexity. It
reflects the cautious and conservative orientation. She has atypical processing that involves
more scanning shift than common and focus on minute features of blots. Inappropriate in her
disregard for the totality of situations. She striving to accomplish more than may be
reasonable in light of current functional capacities. Impact of failure include experience of
frustration. Patient’s quality of processing leads to adjustment difficulties. She scans hostility
and haphazardly often neglect critical bits or cues that exists in a stimulus field which creates
faulty translation of cues that are present, leading to less effect patterns of behaviour.
Cognitive Mediation
Patient’s mediation is usually appropriate for the situations. It suggests that the basic
ingredient
necessary for conventional reality testing is intact. There is a moderate elevation in the
incidence of meditational dysfunction. Patient have less conventional, more individualistic
responses occurred even in the situations that are simple and precisely defined. Patient have
problem in reality testing.
Ideation
The orientation to avoid complexity overlays the inconsistency in conceptual thinking and the
end product is much greater inefficiency because the array of possible conceptualisation is
reduced significantly. Vulnerable to less sophisticated thinking and have difficulty in
adapting effectively in complex environment. Ideation sets and values of the individual are
well fixed and relatively inflexible. Thinking is inconsistent reductant, characterised by
noticeable episodes of slippage such as difficulty in coming to closure. Patient is distinct
tendency to defensively substitute fantasy for reality in stressful situations more often than do
most people, clarity of conceptual thinking is missing, consist faulty judgements.
Self Perception
Exaggerated self involvement, inflated sense personal worth that tends to dominate the
individual’s perception of the world. Find it difficult to establish and maintain deep and
meaningful interpretation. Patient tends to be more involved with herself. sustain favourable
judgements concerning the self, which leads to neglect of external world. She engages in self
inspecting behaviours routinely. Ruminations about body, self-image, indicate disconcerting
sense of vulnerability.
Interpersonal Perception and Behaviour
Patient is less socially mature and have fewer social skills, experience frequent difficulties
when interacting with environment. Experience social chaos and personal dissatisfaction. She
has more passive role in relationships, avoid responsibility of decision making, less prone to
search out new solutions, initiate new patterns of behaviour. Patient acknowledges and
expresses needs for closeness in ways similar to most people. She is amenable to close
relationships and open to routine tactile exchanges as one way of creating and sustain those
relations. Patient is interested in others but dies not understand, misread people and
misinterpret social gestures. She tries to engage in interpersonal behaviour adaptive for
situations.
Rating Scales:
Hamilton Anxiety Rating Scale (HAM-A) - 26
Hamilton Depression Rating Scale (HAM-D) - 23
Summary
The index patient has inadequate levels of attention and concentration. She reported
symptoms of feelings of anxiety, irritability, loss of interest, sleep disturbances. She
frequently tends to get inundated with negative emotions and hold a pessimistic outlook
towards events. She has significant interpersonal difficulties and often experiences conflicts
in the domain of interpersonal functioning. She has passive aggressive tendencies along with
suppression of emotion yet impulsive which makes it even more difficult for her to
participate in healthy social interactions. Whenever there is a stressor, she experiences
marked inability to take decisions rationally. She has developed maladaptive coping skills
over the years to deal with the hostile home environment which can be seen in her ways of
using defences like splitting, identification, acting out and primitive idealisation.
Impression
Test findings indicate that patient has mild symptoms of depression and moderate symptoms
of anxiety along with low stress tolerance, impulsivity, limited social skills and lesser
resources to deal with stress. She faces significant difficulties in interpersonal relationships
along with sexual disturbances which affect her personal life. Additionally, defiant attitude,
aggressive and acting out tendency interferes with her overall functioning.
Case Conceptualisation
Based on Biosocial Model by Marsha Linehan:

Case Formulation
Based on Biosocial Model by Marsha Linehan:

Precipitants: Her symptoms escalated following prolonged bullying due to her sexual
orientation and hairstyle by her classmates, further exacerbated by inadequate support from
college authorities and conflict with the Dean. This traumatization triggered heightened
anxiety, characterized by gastrointestinal distress, insomnia, somatic complaints, and fatigue.
The patient was excessively worried about the repercussions of her conflict with college
authorities as she did not consider their responses fair and effective. During this time, she
visited home where she got into conflicts with her sister and mother which deteriorated her
symptoms further. She fears that when her family discovers the matter, they would not
understand her or support her instead they would blame her for everything. These thoughts
are making it difficult for the patient for function optimally.

Longitudinal View of Cognition and Behaviour: The patient’s childhood experiences both
at home and school were traumatizing for her. At school she mostly got into conflicts with
her classmates and later got into trouble with the school authorities due to her impulsive
behaviour. Her negative affectivity made it difficult for her to make friends and maintain
friendships in school. She was highly emotionally sensitive during her formative years which
was mostly responsible for her unstable self- image. Criticism from teachers would trigger
intense ideas of guilt and shame resulting in inappropriate outbursts of anger towards
authority figures. At home her emotions, feelings and thoughts were mostly invalidated by
her parents which developed a sense of emptiness in her. During this time, she struggled with
her self-identity and she became confused about her sexual orientation. As she grew up, she
adopted maladaptive coping strategies to deal with her inability to regulate emotions and her
ongoing interpersonal conflicts resulted in multiple unstable romantic relationships. She
continually seeks validation from others which oscillates her beliefs about self from
overvaluation to devaluation both for herself and for others.

Cross Sectional View of Current Cognition and Behaviour: The current problematic
situation is that the patient is blaming herself for being impulsive and reacting towards her
bullies and Dean with inappropriate anger which has created bigger issue for her patient. She
is unable to sleep for the past many days due to her fear of being rusticated from the college.
She is also experiencing bodily symptoms (palpitations, sweating, inability to relax, body
aches) apart from depressed mood, reduced energy, attention and concentration. She is
preoccupied with ideas of guilt and unstable self-image which got triggered due to her
interpersonal conflict in the college and later at home. Lack of validation and support from
home induces chronic feelings of emptiness in her. She is indulged in self-loathing spending
most of her time in bed and currently her inability to regulate her emotions is making it
difficult for her to address existing conflicts in a productive manner. She is trying to function
with considerable difficulty owing to her reduced energy and bodily symptoms.

Working Hypothesis: The patient’s journey towards borderline personality disorder began
early in her development with the emergence of poor impulse control, likely influenced by
biological vulnerabilities and environmental stressors.
This trait, coupled with extreme emotional lability shaped by her caregiving environment,
perpetuated her baseline emotional sensitivity. Compounded by a lack of familial validation
since childhood, she anticipates further blame and invalidation, hindering her willingness to
disclose her distress. Enduring emotional invalidation during formative years contributed to
her impaired emotion regulation, culminating in impulsive behaviours and intense
interpersonal conflicts. Oscillating between a fluctuating self-identity ranging from achiever
to self-loathing, she grapples with a negative self-image and pervasive feelings of emptiness
and loneliness. As she transitioned into adolescence, identifiable features and maladaptive
coping strategies emerged, indicating heightened risk for current symptoms.

Throughout her development, reciprocal reinforcing transactions between her biological

vulnerabilities and environmental risk processes potentiated emotion dysregulation and
behavioural dyscontrol, leading to negative cognitive and social outcomes. Moreover,
patient’s maladaptive traits interfered with healthy emotional development and evoked
negative responses in interpersonal relationships, exacerbating her symptoms and
contributing to feelings of emptiness and loneliness.

Prognostic Factors]

Good factor: Regularity in therapy session, educated, motivation to get better

Poor factor: Interpersonal conflicts

Rationale for Therapy:

In the present case, Dialectical Behaviour Therapy (CBT) is applied. Dialectical Behavior
Therapy (DBT) aligns with all aspects of patient’s case model, making it a suitable
therapeutic approach for her treatment:

1. Poor Impulse Control: DBT addresses poor impulse control by teaching Patient
specific skills to manage impulsive behaviours effectively. Through modules such as
Emotion Regulation and Interpersonal Effectiveness, she learns to recognize triggers
for impulsive actions and develop alternative responses.
2. Extreme Emotional Lability: The emotion regulation component of DBT directly
targets Patient's emotional lability. By teaching her skills to identify and label
emotions, tolerate distress, and modulate intense feelings, DBT helps her achieve
greater emotional stability and resilience.
 3. Reciprocal Reinforcing Transactions: DBT emphasizes the interaction between
biological vulnerabilities and environmental risk processes. By providing Patient with
concrete tools to cope with environmental stressors and regulate her emotions, DBT
interrupts the cycle of negative reinforcement, empowering her to respond adaptively
to challenges.
4. Impact on Interpersonal Relationships: DBT's Interpersonal Effectiveness module
focuses on improving communication skills, setting boundaries, and navigating
interpersonal relationships effectively. By addressing maladaptive patterns of
interaction, DBT helps Patient cultivate healthier relationships and reduce
interpersonal conflicts.

Goals

Short-Term Goals Long-Term Goals

 To form the therapeutic alliance with the  To enchanted emotion regulation
patient.  Cultivate healthier interpersonal
 To Psycho educate the patient about her relationships
illness symptoms, triggers and treatment  Foster a stable and coherent sense of self
options  Learn to recognise and control impulsive
 To conduct psychometric assessments behaviour through mindfulness
with the patient to understand her techniques
personality structure better.  Build a repertoire of healthy coping
 To reduce anxiety symptoms through mechanisms
activity scheduling.  Develop skills for independent loving by
 Improve sleep pattern through sleep pursuing academic goals
hygiene.  Relapse prevention
 Improve self-care routines, eating  Review
healthy, exercising
Process of Therapy

The patient was called once a week with initial sessions being devoted to taking history,
working on therapeutic alliance followed by assessments. The patient was then explained
about her illness and its symptoms, triggers and how its manifestation has an impact on her
personal and social domains of her life. She was explained in detail about the therapeutic
situation as to what is it and how will it be done. She was also educated about sleep hygiene
along with anxiety management and relaxation techniques.

In the middle phase, sessions focused on providing a safe space to the patient for ventilation,
which helped the patient express her fears. Therapeutic techniques were implemented
Develop effective coping strategies and skills to manage intense emotions and reduce
emotional dysregulation, leading to more stable mood states and fewer interpersonal
conflicts. Reduce acute symptoms such as emotional dysregulation, impulsivity, and self-
harm through coping strategies taught in therapy sessions. Cultivate healthier interpersonal
relationships by improving communication skills, setting boundaries, and fostering empathy
and understanding in interactions with others. Foster a stable and coherent sense of self by
exploring personal values, goals, and strengths, leading to greater self-awareness and self-
acceptance. Learn to recognize and control impulsive behaviours through mindfulness
practices, distress tolerance techniques, and problem-solving skills, leading to more
thoughtful and intentional decision-making. Challenge negative self-beliefs and develop a
more positive and realistic self-image through therapy interventions, leading to increased
self-confidence and self-worth. Build a repertoire of healthy coping mechanisms to manage
stress, anxiety, and other triggers, reducing reliance on maladaptive coping strategies such as
self-harm or excessive masturbation. Improve communication skills and assertiveness to
navigate interpersonal relationships more effectively and reduce conflict.

Lastly, the termination phase will focus on reviewing the patient’s progress and areas of
improvement. For relapse prevention, the patient will Learn to recognize early warning signs
of symptom exacerbation and implement preventive measures to maintain progress and avoid
relapse. Arrangements for follow-up sessions will be made with the patient for the review
purpose.
Initial Phase (1-6 sessions)

Session 1: Intake Session

Objective: To explore the chief complaints of the patient and to familiarize the patient with
the therapy process.

Session Conducted: During the intake session, patient was warmly welcomed to the therapy
setting and encouraged to express her concerns freely. She shared her primary concerns,
which included symptoms of anxiety, palpitations, fear of conflict repercussions, epigastric
discomfort, and sleep disturbances. Through an open dialogue, patient provided insight into
her situation which evoked symptoms she has been unable to endure further. She shared
details of the event that led her to seek help. Patient was briefed about the process of therapy
ad realistic expectations were set.

Session 2:

Objective of the session: To take the history and MSE from the patient.

Session conducted: During the history-taking and Mental State Examination (MSE) session,
patient's presenting concerns were explored in depth. She provided a detailed account of her
personal and family history, including significant life events and past mental health treatment
experiences. Patient described experiencing symptoms of anxiety, palpitations, fear of
academic repercussions due to bullying and recent interpersonal conflict with college
authorities, epigastric discomfort, and sleep disturbances. She appeared anxious and restless,
displaying fidgeting behaviours and occasional signs of distress. Patient's affect was
congruent with her reported emotional experiences, displaying signs of fear and worry. She
maintained good eye contact and circumstantial in her interactions. Overall, patient presented
with symptoms consistent with BPD (previously diagnosed) and anxiety disorder, warranting
further assessment and intervention. She was psychoeducated about her symptoms, possible
triggers and discussed potential treatment options, emphasizing the importance of
collaborative goal setting and active participation in therapy.

Session 3

Objective of the session: To administer the psychometric assessments.

Session conducted: Patient was called on a shorter duration for the assessments. The purpose
of the assessments was explained to the patient. Tests administered were: Draw-a-person test
(DAPT), Millon’s Clinical Multiaxial Inventory-III (MCMI-III), Thematic Apperception Test
(TAT) and Rorschach Inkblot Test.

Session 4:

Objective of the session: Introduction to DBT model of psychopathology and psychotherapy

Session Conducted: In the initial session, the patient was introduced to the core principles of
Dialectical Behavior Therapy (DBT) and its four modules: mindfulness, distress tolerance,
emotion regulation, and interpersonal effectiveness. Through psychoeducation, patient gained
an understanding of how these modules will be integrated into her treatment plan to address
her distressing symptoms. A comprehensive assessment was conducted to identify patient's
treatment goals and prioritize target behaviours for intervention. To begin building
mindfulness skills, the Patient was introduced to the concept of "Wise Mind" and guides her
through mindfulness exercises such as mindful breathing and body scan.

Patient is encouraged to practice these exercises daily as part of her homework assignment,
with the aim of increasing her awareness of present-moment experiences and laying the
foundation for emotion regulation.

Session 5: Mindfulness skills (On Going)

Objective of the session: To introduce grounding techniques and sleep hygiene.

Session conducted: In this session, the patient's experiences with mindfulness exercises from
the previous session were reviewed and any questions or challenges that arose were
addressed. Psychoeducated about types of mind and their impact on our behaviour. Building
upon her existing mindfulness practice, the therapist introduces additional techniques such as
mindful observation and non-judgmental awareness. These exercises aim to help patient
cultivate a greater sense of self-awareness and acceptance of her thoughts, emotions, and
sensations. It will also help her relax and increase her focus.

As homework, Patient is assigned daily mindfulness practice and provided with a

mindfulness practice exercise to record her experiences and observations. Through consistent
practice, patient will develop greater mindfulness skills, which are essential for emotion
regulation and distress tolerance.
Middle Phase (7-11) Treatment Plan

Session 6: Distress Tolerance Skills

Objective of the session: To discuss case conceptualisation; to introduce the concept of

cognitive distortions and thought restructuring.
Session Plan: In this session, patient learns distress tolerance techniques to cope with intense
emotions and crisis situations effectively. The therapist introduces the acronym STOP (Stop,
take a step back, Observe, proceed mindfully) as a tool for interrupting impulsive reactions
and gaining perspective in distressing moments. Patient also learns the TIP skill
(Temperature, Intense exercise, paced breathing) to rapidly reduce emotional arousal and the
ACCEPTS skill (Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts,
Sensations) for distraction and self-soothing. Role-playing scenarios will allow patient to
practice applying these skills in simulated distressing situations.

As homework, patient will be assigned a distress tolerance worksheet to identify personal

triggers and effective coping strategies for managing distress.

Session 7

Objective: Emotion regulation Skills

Session Plan: In this session, the therapist will be teaching patient emotion regulation
strategies to manage intense emotions effectively. Patient learns to identify and label her
emotions using the "Emotion Thermometer" technique, which helps her track the intensity of
her emotions on a scale from 1 to 10. The therapist introduces the CHECK THE FACTS skill
to challenge and validate the accuracy of her emotional interpretations, promoting a more
balanced perspective. Patient will also learn the opposite action skill, which involves acting
opposite to her emotional urges to reduce emotional intensity. Through psychoeducation and
experiential exercises, Patient will gain insight into the function of emotions and the role of
invalidating environments in emotion dysregulation.

As homework, patient will be assigned an emotion regulation diary card to track her
emotional experiences and responses throughout the week, with the goal of identifying
patterns and triggers for further exploration in therapy.

Session 8

Objective: To continue Emotion Regulation Skills

Session Plan: Building on the previous session, patient will continue to develop her emotion
regulation skills. The therapist reviews patient's diary card entries to identify patterns in
emotional responses and triggers. Patient learns techniques to reduce emotional vulnerability,
including self-care practices such as exercise, healthy eating, and relaxation exercises. The
therapist will assist the patient in identifying areas for improvement in her self-care routine
and collaborates with her to develop a personalized self-care plan. Through this session,
patient will gain a deeper understanding of the connection between self-care and emotion
regulation, empowering her to take proactive steps in managing her emotional well-being.

Session 9

Objective: Interpersonal Effectiveness Skills

Session Plan: The review regarding the week and homework.

In this session, patient will be focused on improving her interpersonal effectiveness skills.
The therapist will introduce the DEAR MAN (Describe, Express, Assert, Reinforce, Stay
Mindful, appear confident, Negotiate) technique for assertive communication and boundary-
setting. Patient learns to identify her needs and effectively communicate them to others while
maintaining self-respect and interpersonal relationships. Role-playing exercises will provide
patient with opportunities to practice assertive communication in various interpersonal
scenarios. By the end of the session, patient gains confidence in her ability to assert her needs
and navigate interpersonal interactions with greater effectiveness.

Session 10

Objective: Interpersonal Effectiveness Skills to be continued

Session Plan: Building on the previous session, patient continues to develop her
interpersonal effectiveness skills. The therapist reviews role-play exercises and provides
feedback on patient's assertiveness and boundary-setting techniques. Patient learns strategies
for managing conflict and negotiating needs in relationships while maintaining self-respect
and mutual understanding. Through experiential exercises and group discussion, Patient gains
insight into the importance of effective communication and problem-solving in interpersonal
relationships. As homework, Patient is assigned a communication log to track her attempts at
assertive communication and the outcomes of interpersonal interactions, providing
opportunities for further skill development and self-reflection.

Session 11

Objective: Integration and Review

Session Plan: In this session, the therapist reviews Patient's progress in therapy and
celebrates her achievements thus far. Patient reflects on her experiences with DBT skills and
discusses any challenges encountered during treatment. The therapist encourages patient to
integrate mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness
skills into her daily life, emphasizing the importance of consistent practice for skill
acquisition and mastery. Patient to be encouraged to engage in a mindfulness meditation
exercise to reinforce the benefits of mindfulness for emotional regulation and stress
management. By the end of the session, Patient feels empowered to continue applying DBT
skills in her ongoing recovery journey.

Session 11

Objective of the session: Relaxation techniques

Session Plan: In this session, Patient will learn various relaxation techniques to promote
stress reduction and enhance emotional well-being. The therapist introduces progressive
muscle relaxation, deep breathing exercises, and guided imagery as effective relaxation
methods. Patient practices each technique in session, focusing on releasing tension and
promoting relaxation throughout the body. The therapist emphasizes the purpose of relaxation
techniques in reducing physiological arousal and promoting a sense of calmness and inner
peace.

As homework, patient will be assigned a relaxation practice schedule, incorporating daily

practice of the techniques learned in session. Additionally, the therapist provides audio
recordings or written instructions for patient to use as guidance in her relaxation practice at
home. Continuing from the previous session, Patient reviews her experiences with practicing
relaxation techniques at home. The therapist facilitates a discussion on the role of relaxation
in stress management and anxiety reduction, highlighting the benefits of regular practice for
overall well-being. Patient shares any challenges or barriers encountered in her relaxation
practice, and together with therapist problem-solves strategies for overcoming them. The
therapist reinforces the importance of self-care and relaxation in maintaining emotional
balance and resilience, encouraging patient to prioritize these practices in her daily life. By
the end of the session, patient will be equipped with effective relaxation techniques to
manage stress and promote relaxation in her ongoing recovery journey.

Termination (12-15 sessions)

Session 12: Application of Skills

Objective: To initiate termination and give information regarding relapse prevention

Session Plan: In this session, patient applies DBT skills to real-life scenarios and challenges
encountered outside of therapy. The therapist facilitates a discussion on how mindfulness,
distress tolerance, emotion regulation, and interpersonal effectiveness skills can be utilized in
various situations to cope with difficult emotions and interpersonal interactions. Patient
shares her experiences with applying DBT skills and receives feedback and validation from
the therapist. Role-playing exercises provide opportunities for patient to practice integrating
DBT skills into her daily life, reinforcing their effectiveness in promoting adaptive coping
and resilience. By the end of the session, patient feels empowered to continue applying DBT
skills independently and is encouraged by her progress in managing life's challenges. She will
be briefed about relapse prevention techniques using the following worksheets.

Session 13: Review and Closure

Objective: To initiate termination and give information regarding relapse prevention

Session Plan: In the final session, the therapist conducts a comprehensive review of patient's
progress throughout the DBT therapy process. Patient reflects on her achievements and
milestones reached during treatment, celebrating her growth and resilience in navigating her
recovery journey. The therapist discusses relapse prevention strategies with patient,
emphasizing the importance of maintaining gains post-therapy and accessing ongoing support
as needed. Resources for continued support, such as support groups, self-help materials, and
referrals for continued therapy, are provided to patient. By the end of the session, Patient
feels supported and equipped with the skills and resources necessary to continue her journey
towards emotional healing and well-being.

Therapist’s reflection

Upon completion of therapy with Patient, I reflected on the progress made and the therapeutic
journey we embarked on together. Throughout our sessions, I witnessed patient's dedication
to her healing process and her resilience in confronting and managing her symptoms. From
our initial intake session till now, patient demonstrated a remarkable commitment to
implementing skills and techniques into her daily life.

I also reflected on the challenges patient faced during therapy, including moments of self-
doubt, setbacks, and relapses. These moments served as opportunities for exploration,
learning, and growth, reinforcing the importance of a compassionate and nonjudgmental
therapeutic approach. Collaboratively, we are working through these challenges, identifying
strengths and building upon them to foster resilience and self-efficacy.

As therapy continues, I feel a sense of hope in patient's progress and possible transformation.
While therapy provides a structured framework for healing, it is ultimately patient's
dedication, courage, and perseverance that seems to be propelling her forward on her journey
toward recovery. Looking ahead, I feel hopeful for her continued growth and well-being,
knowing that she is now learning skills and strategies to navigate life's challenges with
progressing confidence and resilience.