PSY 913: ADVANCED PRACTICUM IN CLINICAL ASSESSMENT,

PSYCHOTHERAPY AND PSYCHOPATHOLOGY

LECTURER: PROFESSOR HARRY OBI-NWOSU

ASSIGNMENT: CASE REPORT ON THE USE OF COGNITIVE

BEHAVIOUR THERAPY (CBT), ACCEPTANCE AND COMMITMENT

THERAPY (ACT) AND PERSON-CENTERED THERAPY (PCT)

SUBMITTED BY

ONYEKACHI OSMOND OKONKWO

2024147001PS

FEBRUARY, 2025
 CASE REPORT USING COGNITIVE BEHAVIOUR THERAPY (CBT)

Miss A.B is a 32 years old female who was referred to the department for Psychotherapy
(Cognitive behaviour Therapy)

Bio-data

Name A. B

Age 32 years

Gender Female

Religion Christian

State Anambra

Marital status Single

Source of Referral Consultant Psychiatrist

Reason for referral Psychological Assessment

Source of Information Client

Date 24th January 2025

PRESENTING COMPLAINT:

Feelings of hopelessness, 6 months

Lack of energy, 6 months

Poor sleep and appetite, 6 months

Intense sad feelings, 6 months.

HISTORY OF PRESENTING COMPLAINT:

A.B. reports the depressive symptoms began gradually approximately six months prior,
following a difficult breakup with her long-term Fiancé. She describes the relationship as
“very significant” and reports feeling “completely abandoned” due to the breakup. Initially,
she experienced sadness, tearfulness, and loss of interest in her usual activities such as Choir
rehearsals, which she attributed to the breakup and expected to dissipate over time. However,
the symptoms persisted and worsened. She now describes feeling persistently sad, empty, and
hopeless, even when thinking about things she used to enjoy. The anhedonia is profound; she
no longer finds joy in spending time with friends, going to her choir rehearsal, or even
spending time with her friend who is a hair dresser in her shop – activities that previously
brought her much pleasure. Her appetite has significantly decreased, and she reports having
to force herself to eat small meals. This has resulted in noticeable weight loss compared to
photos of her prior to PC. She experiences significant sleep disturbances, typically taking a
long time to fall asleep and then waking up several times during the night, often unable to go
back to sleep. She feels constantly fatigued, even after a full night’s sleep, and describes her
energy levels as “nonexistent.” This fatigue makes it extremely difficult to manage her work
as a teacher. She struggles to prepare lesson notes, has difficulty maintaining her patience
with her students, and feels overwhelmed by the demands of the job. She reports having
significant difficulty concentrating, making even simple tasks feel monumental. While she
denies any active suicidal ideation, she admits to having passive suicidal thoughts, wishing
she “could just disappear” or that “something would happen” to her. She reports feeling like
a burden to her family and friends and has started isolating herself from them.

PAST PSYCHIATRIC HISTORY:

Nil

PAST MEDICAL HISTORY:

Client is generally healthy. She reports occasional tension headaches, which is being
managed with over-the-counter pain medication. No history of hospitalizations, surgeries, or
chronic medical conditions.

FAMILY HISTORY:

Client is from a monogamous family of 2 children. Client is the first-born child of her
parents.

She describes her family as middle class.

Client’s father is late A.D is a 65 years old retired teacher. He has a Bachelors in Science
education

Client’s mother A. M, is 55 years old civil servant with a bachelors in Accounting.

Client’s younger sibling (male) is currently 24 years and is in 300 level at COOU
Client describes her childhood as relatively stable and happy, with supportive and loving
parents. She reports a close relationship with her brother, although she hasn’t been
communicating with them as much lately due to her depression.

PERSONAL HISTORY:

Client was born on July 1992. She claimed to have been born through SVD. No
complications at birth were reported. Developmental milestones were normal.

EDUCATIONAL HISTORY

Client reported that her educational journey has always been a pleasant one, and currently,
she has completed her Bachelor’s degree in Education and has been working as a secondary
school teacher for the past eight years. She was a good student and enjoyed learning.

She reported having a good relationship with her teachers while in school and she never had
issues with school authorities.

OCCUPATIONAL HISTORY

Client works as a Secondary school teacher and previously enjoyed her job. She is now
struggling with the demands of her job due to her depression, experiencing difficulty with
lesson planning, classroom management, and interacting with colleagues. She fears she is not
performing her duties adequately and worries about the impact on her students and her career.

PSYCHOSEXUAL HISTORY

Client identifies as a woman. She attained puberty at the age of 13. She is heterosexually
oriented. She reports being sexually active in the past, primarily within the context of her
previous long-term relationship of 5 years. She reports a decreased interest in sex since the
breakup and has not been in a relationship since.

DRUG HISTORY

Denies any use of illicit drugs or misuse of prescription medications. Reports occasional use
of over-the-counter pain medication for tension headaches. Does not drink alcohol or smoke.

FORENSIC HISTORY

Nil

PREMORBID PERSONALITY
C = calm and gentle

H = Singing

A = Resilient

R = very religious

M = happy

PRESENT LIVING CONDITION

Client is personally staying in a rented 1-bedroom apartment. She lives alone and takes care
of her responsibilities.

MENTAL STATUS EXAMINATION

Appearance & behaviour: client presents as well-groomed but her clothes appear slightly
ruffled. She appears sad and tired, with dark circles under her eyes. Her posture is slumped,
and she avoids eye contact throughout the interview. She was cooperative during the
interview, although her responses are delayed and she speaks softly. She fidgets with her
hands and occasionally sighs deeply.

Speech: speech is coherent, slow, and soft

Mood: dysthymic

Affect: restricted and blunted

Thought process: Logical

Thought content: Preoccupied with feelings of sadness, hopelessness, and worthlessness.

She expresses concerns about being a burden to others and ruminates about her past
relationship. No active suicidal ideation at this time, but admits to passive suicidal thoughts

COGNITION

Orientation: client is oriented to time, person or place.

Attention and concentration: impaired

Insight: Limited. Acknowledges feeling depressed but struggles to understand the extent to
which it is impacting her life and believes she should be able to “just snap out of it.”

Judgment: Good
TEST ADMINISTERD

Beck’s Depression Inventory – BDI

TEST TAKING BEHAVIOUR:

Client was calm, cooperative, throughout the test taking process.

TEST RESULT:

Client BDI score of 32 falls under the classification of sever depression.

IMPRESSION

The client’s assessment indicates the presence of Major depressive disorder. Diagnosis was
based on case history, test results and clinical observations in accordance with DSM-V
criteria.

Psychological treatment suggests

 Individual psychotherapy (CBT)

Clinical Report for CBT Session One (1)

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Establish rapport and build therapeutic alliance.

2. Assess the client’s understanding of her condition and expectations for therapy.
3. Introduce the cognitive-behavioral model and explain the connection between thoughts,
emotions, and behaviors.
4. Identify and explore the client’s core negative beliefs and automatic thoughts related to
her breakup and current depressive symptoms.

Session Summary

The session began with the therapist introducing the structure and goals of CBT. The client,
A.B., appeared cooperative but visibly fatigued and emotionally withdrawn. She expressed
skepticism about therapy but acknowledged her need for help. The therapist normalized her
feelings and emphasized the collaborative nature of CBT. A.B. was guided to identify her
automatic thoughts, particularly those related to her breakup. She reported thoughts such as,
“I’ll never find love again,” “I’m a burden to everyone,” and “I’m worthless.” These thoughts
were linked to her feelings of sadness, hopelessness, and low energy. The therapist introduced
the concept of cognitive distortions (e.g., catastrophizing, personalization) and helped A.B.
recognize how these distortions were maintaining her depressive symptoms. A.B. was
assigned homework to monitor her automatic thoughts and emotions using a thought record
sheet. She was also encouraged to engage in one pleasurable activity (e.g., listening to music)
before the next session.

Client’s Response

A.B. was initially hesitant but gradually engaged in the session. She expressed relief at being
able to verbalize her thoughts and feelings. However, she remained doubtful about her ability
to change.

Therapist’s Observations

A.B.’s affect was blunted, and her speech was slow and soft. She demonstrated limited
insight into the connection between her thoughts and emotions but showed willingness to
explore this further.

Plan for Next Session

1. Review homework and address any challenges.

2. Continue identifying and challenging cognitive distortions (irrational thoughts).
3. Introduce behavioral activation to address anhedonia and low energy.

Clinical Report for CBT Session Two 2

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review homework and reinforce the cognitive-behavioral model.

2. Introduce behavioral activation to increase engagement in meaningful activities.
3. Continue identifying and challenging cognitive distortions.
Session Summary

A.B. reported partial completion of her homework. She identified several automatic thoughts,
such as, “I’m not good enough” and “No one cares about me.” The therapist validated her
efforts and helped her reframe these thoughts using evidence-based questioning. For example,
A.B. was guided to consider evidence that contradicted her belief of being a burden (e.g., her
family’s continued support). The therapist introduced behavioral activation, emphasizing the
importance of engaging in activities to improve mood and energy levels. A.B. agreed to
schedule two small, manageable activities (e.g., taking a short walk, calling a friend) before
the next session. The session also explored A.B.’s core belief of worthlessness, which
appeared to stem from her breakup. The therapist helped her differentiate between the end of
a relationship and her inherent self-worth.

Client’s Response

A.B. appeared more engaged and hopeful. She expressed appreciation for the structured
approach of CBT and reported feeling slightly less overwhelmed after the session.

Therapist’s Observations

A.B.’s affect was less blunted, and she maintained better eye contact. She demonstrated
improved insight into the connection between her thoughts and emotions.

Plan for Next Session

1. Review behavioral activation homework and address barriers.

2. Continue challenging cognitive distortions and core beliefs.
3. Introduce relaxation techniques to address sleep disturbances.

Clinical Report for CBT Session Three (3)

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review homework and reinforce progress.

2. Introduce relaxation techniques to improve sleep.
3. Continue addressing core beliefs and cognitive distortions.
Session Summary

A.B. reported completing her behavioral activation homework, which included taking a short
walk and calling a friend. She acknowledged a slight improvement in mood after these
activities. The therapist praised her efforts and encouraged her to gradually increase the
frequency and variety of activities. The session focused on addressing A.B.’s sleep
disturbances. The therapist introduced relaxation techniques, such as deep breathing and
progressive muscle relaxation. A.B. practiced these techniques in session and agreed to
incorporate them into her bedtime routine. The therapist also continued to challenge A.B.’s
core belief of worthlessness. A.B. was guided to identify strengths and accomplishments
(e.g., her career as a teacher, her resilience) that contradicted this belief.

Client’s Response

A.B. appeared more optimistic and reported feeling less fatigued. She expressed gratitude for
the relaxation techniques and stated that she was beginning to feel more in control of her
emotions.

Therapist’s Observations

A.B.’s speech was less slow, and her posture was less slumped. She demonstrated improved
insight and engagement in the therapeutic process.

Plan for Next Session

1. Review relaxation techniques and sleep patterns.

2. Continue behavioral activation and cognitive restructuring.
3. Explore strategies to improve concentration and work performance.

Clinical Report for CBT Session Four (4)

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review homework and reinforce progress.

2. Address work-related challenges and improve concentration.
3. Continue cognitive restructuring and behavioral activation.
Session Summary

A.B. reported improved sleep quality after incorporating relaxation techniques. She also
completed her behavioral activation homework, which included attending a choir rehearsal.
She described feeling a sense of accomplishment and reconnecting with her love for music.
The session focused on addressing A.B.’s difficulties with concentration and work
performance. The therapist introduced strategies such as breaking tasks into smaller steps,
prioritizing tasks, and setting realistic goals. A.B. agreed to apply these strategies to her
lesson planning and classroom management. The therapist also continued to challenge A.B.’s
cognitive distortions, particularly those related to her breakup. A.B. was guided to reframe
thoughts such as, “I’ll never find love again,” to more balanced thoughts, such as, “I can learn
from this experience and build healthier relationships in the future.”

Client’s Response

A.B. appeared more confident and hopeful. She reported feeling less overwhelmed at work
and expressed a renewed sense of purpose.

Therapist’s Observations

A.B.’s affect was brighter, and she maintained good eye contact. She demonstrated significant
progress in challenging her negative thoughts and engaging in meaningful activities.

Plan for Next Session

1. Review work-related strategies and progress.

2. Continue cognitive restructuring and behavioral activation.
3. Prepare for termination and relapse prevention.

Clinical Report for CBT Session Five (Termination Session)

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review progress and reinforce coping strategies.

2. Address any remaining concerns or challenges.
3. Develop a relapse prevention plan and prepare for termination.
Session Summary

A.B. reported significant improvement in her mood, energy levels, and sleep quality. She had
successfully reintegrated into her choir and reported feeling more connected to her friends
and family. She also described feeling more confident and effective at work. The session
focused on reviewing A.B.’s progress and reinforcing the coping strategies she had learned.
The therapist and A.B. collaboratively developed a relapse prevention plan, which included
identifying early warning signs of depression, maintaining behavioral activation, and
continuing to challenge negative thoughts. The therapist emphasized the importance of self-
compassion and encouraged A.B. to seek support if needed. A.B. expressed gratitude for the
therapy and stated that she felt equipped to manage her emotions independently.

Client’s Response

A.B. appeared confident and optimistic. She expressed a sense of closure and readiness to
move forward.

Therapist’s Observations

A.B.’s affect was bright, and her speech was clear and confident. She demonstrated
significant improvement in all areas of functioning and showed a strong understanding of the
skills learned in therapy.

Termination

Therapy was terminated with a plan for follow-up if needed. A.B. was encouraged to
continue practicing the skills learned in therapy and to reach out for support if she
experienced any setbacks.

Overall Progress

A.B. showed significant reduction in her initial presenting complaints, including feelings of
hopelessness, low energy, poor sleep, and intense sadness. She demonstrated improved mood,
increased engagement in meaningful activities, and better coping skills. Therapy was
successful in helping her regain a sense of control and purpose in her life.
 CASE REPORT USING PERSON – CENTERED THERAPY (PCT)

Mr J. E. is a 34 years old male. He is dark in complexion, single and was referred to the
department for personality assessment and individual psychotherapy.

BIO-DATA

Name J. E

Age 34 years

Gender Male

Religion Christian

State Rivers

Marital status Single

Source of Referral Dr Nwiyi (Consultant Psychiatrist)

Reason for referral Personality Assessment

Source of Information Client

Date 21st January 2025

PRESENTING COMPLAINT:

Excessive smoking of cigarette

Excessive smoking of Rohypnol, tobacco and codeine

Excessive smoking of cracks and cannabis

HISTORY OF PRESENTING COMPLAINT:

Patient revealed that he started smoking cannabis at the age of 15. However, prior to that
time, he was introduced to cannabis by his friend while in SS2. Because he was in a boarding
school, he claimed to had only chewed cannabis and continued in that process for two years.
He was 13 years of age when he was introduced to cannabis

Client’s first attempt at smoking was in SS3 with his friends. He claimed to have smoked a
stick of cigarette. He claimed to have started drinking alcohol at that period. He recalled that
his mother used to bring pack of bottle water for him, and once it is empty, he would pour
apocalypso which he revealed was an alcoholic drink. He also began smoking skunk, which
he referred to as another grade of marijuana. He initially started with the use of tobacco
substances at age 15, and claimed he was using tobacco at least three times a week. When
asked how he felt after his attempt, client said it was choking at first, but got used to it in the
long run. He revealed that he has been taking skunk since 2010 till date. He said skunk is
more potent than the normal marijuana. His first attempt at taking Colorado was in 2017, he
claimed to had only taken it 6 times and had since then stopped. He claimed to be a heavy
user of Rohypnol, tobacco and codeine and also like skushi since he gained admission into
the university at 17years of age and didn’t stop until 2018. He claimed to have stopped the
use of psychoactive substances for a period of 5 months until when a drug dealer called him
again. Client says he buys all these substances with the money he gets from cyber-crime and
also moved to stealing sometimes from his mother.

PAST PSYCHIATRIC HISTORY:

Client was once taken to a private rehabilitation centre for 3 months but left after a month,
convincing his family members that he was okay and promised not to go back to drugs. He
however reiterated and was back to use of substance immediately after discharge.

PAST MEDICAL HISTORY:

Nil

FAMILY HISTORY:

Client is from a monogamous family of 3 children, 2 males and one female. Client is the first
born child of his parents.

Client’s father is late J. O. He was 56 years old when he lost his life after a brief illness. He
was an HND holder in accounting and was a Christian by religion. Cause of illness was not
disclosed.

Client’s mother Mrs F. J, a native of Rivers state is 65 years old and only wife of late J. O.
She is a trader and a Christian by religion. She has three children.

2nd child (Sister): Mrs E. E. is the immediate younger sister to the client. She is 32 years old
and is married with two kids. She resides in Lagos.
3rd child (brother): Mr Daniel Joel is a 28 years old single male student of National Open
University Nigeria (NOUN). He also resides in Lagos.

Client reported that after the death of the father, the intake of psychoactive substances
increased. Client also disclosed that his parents had a very cordial relationship.

PERSONAL HISTORY:

Client was born on April 1991. He claimed that his conception, pregnancy and developmental
milestones were normal and also that his childhood experiences was a happy one.

EDUCATIONAL HISTORY

Client reported to have started school at the age of 2 into ultimate nursery and primary school
from 1992/2000. He proceeded for secondary school education at age 10 into command
secondary, Apata Ibadan, where he spent a year and left due to constant illness. He was
withdrawn and was taken to topmost international comprehensive secondary school from
2001 to 2007. He got admission into Ajayi Crowther University 2007/2011 and was expelled
during his final year sur to psychoactive substance use.

OCCUPATIONAL HISTORY

Client only worked at the Nigerian Army 81 division, Finance department for his I.T
programme while he was still in the university. The I.T programme was scheduled to last for
6 months but client only spent a month. He claimed he was tired of doing the same routine at
the office, so he decided to leave. He is actively engaged in cyber-crime.

PSYCHOSEXUAL HISTORY

Client sees himself as a man, he attained puberty at the age of 12. He is heterosexually
oriented. His first sexual intercourse was with a sex worker, while still in secondary school,
whom he paid the sum of 500 naira to. He claimed to have done this at the age of 15 years.
He continued this process, until he met his fiancée. There is history of risky sexual behaviour
and he had treated STD (sexually transmitted disease) in the past. Client is a single parent, he
has two kids with a woman he intended to marry, and he reported that she left him because of
his excessive use of substances. His first child is a boy who is just 9 years old and the second
child is a girl who is 6 years old.

DRUG HISTORY
As stated in history of presenting complaint.

FORENSIC HISTORY

Client was arrested and detained in police custody for a period of 4 days. He was detained on
the account of hijacking his mother’s bag, fleeing away with it, took her money for substance
use and also on account of his physical aggression.

PREMORBID PERSONALITY

C = calm and gentle

H = sporting activities

A = not reported

R = not reported

M = remorseful

PRESENT LIVING CONDITION

Client is personally staying in a rented 2 bedroom apartment in Lagos state. He has a room
for himself and takes care of his upkeep.

MENTAL STATUS EXAMINATION

Appearance & behaviour: client is tall, dark in complexion, built with no physical
abnormalities. He wore a green shirt with a black short and slippers. He appeared calm, well-
groomed and maintained good eye contact. He was cooperative during the interview.

Speech: speech is coherent, volume is normal, and speech is fluent.

Mood: euthymic

Affect: appropriate

Thought process: normal

COGNITION

Orientation: client is oriented to time, person or place.

Attention and concentration: focused/Fixed

Insight: good
TEST ADMINISTERD

1. Incomplete Sentence Blank College Form (ISBC)

2. Draw a Person Test (DAP).
3. Minnesota Multiphasic Personality Inventory (MMPI)

TEST TAKING BEHAVIOUR:

Client was calm, cooperative, well concentrated and he showed no signs of restlessness
throughout the test taking process.

TEST RESULT:

1. ISBC: client’s ISBC result suggests;

Destructive behaviour (Item 18, 29)
Over concern about the future
Mild depression (items 5, 24, 28, 29, 39)
Insightful (5, 20, 21, 31)
Emotional disturbance
Regret over substance use
2. DAP: Client’s DAP result suggests;
Anxiety, uneasiness over fantasy life, tendencies to act out, aggressive dominance
tendencies, psychosexual and emotional immaturity, probable strong oral and maternal
dependency, power striving usually of physical nature associated with aggression,
excessive sexuality and sensuality, compensatory defences of aggression and social
dominance due to felt inadequacy, guilt possibly associated with stealing.
3. MMPI: On the validity scale, client had a VRIN and TRIN t-score of 54 and 73
respectively. This indicate that profile is valid.
On the frequency scale F, FB and FP, client had a t-score of 61, 92 & 57 respectively. On
the F scale, profile is valid. On the F B scale, profile is valid, and on the F P scale, profile is
valid as well.
On the clinical scale, client had elevations on scale 4 and 9 with a t-score of 67 and 76.
The configuration of the clinical scales puts client’s personality code type at 4-9/9-4
personality code type. This is characterised by:
Marked disregard for social standards and values; antisocial behaviour; poorly developed
conscience, easy morals, fluctuating ethical values: wide array of delinquent acts
(alcoholism, fighting, sexual acting out).
 Narcissistic, selfish, self-indulgent; impulsive, cant delay gratification of impulses; poor
judgement. Acts without considering consequences of acts, fails to learn from experience,
does not accept responsibility for own behaviour, rationalises shortcomings and failures;
blame difficulties on others, low frustration tolerance, moody, irritable causing intense
feelings of anger and hostility which are expressed in occasional emotional outbursts.
Ambitious, energetic, restless, overactive, seeks out emotional stimulation and excitement
uninhibited, extraverted, talkative creates good first impression. Superficial relationships,
incapable of deep emotional ties.

IMPRESSION

The personality profile indicate an antisocial personality disorder. Diagnosis was based on
case history, test results and clinical observations in accordance with DSM-V. Code = 301.7
(F60.2)

Psychological treatment suggests

1. Individual psychotherapy (Person-centered therapy)

2. See occupational therapist for assessment.

Clinical Report for Person-Centered Therapy (PCT) Session 1

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Establish rapport and create a safe, non-judgmental therapeutic environment.

2. Explore the client’s feelings, thoughts, and experiences related to his substance use and
antisocial behaviors.
3. Encourage self-expression and self-awareness.

Session Summary

The session began with the therapist explaining the principles of person-centered therapy,
emphasizing empathy, unconditional positive regard, and congruence. The client, J.E.,
appeared calm and cooperative but initially hesitant to open up. The therapist used reflective
listening to encourage J.E. to share his experiences and feelings. J.E. discussed his long
history of substance use, starting from his teenage years. He expressed feelings of regret and
frustration about his inability to quit despite multiple attempts. He also shared his struggles
with impulsivity, aggression, and his strained relationships with family members, particularly
his mother and ex-fiancée. The therapist validated J.E.’s emotions and emphasized his
inherent worth and capacity for change. J.E. was encouraged to explore his self-concept and
identify areas where he felt disconnected from his values and goals.

Client’s Response

J.E. gradually became more open and engaged as the session progressed. He expressed a
desire to change but admitted feeling overwhelmed by the magnitude of his problems.

Therapist’s Observations

J.E. maintained good eye contact and spoke fluently. His mood was euthymic, but his affect
was tinged with sadness and frustration when discussing his past behaviors and their
consequences.

Plan for Next Session

1. Exploring J.E.’s self-concept and values.

2. Encourage self-reflection on the impact of his behaviors on himself and others.
3. Foster a sense of hope and self-efficacy.

Clinical Report for Person-Centered Therapy (PCT) Session 2

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Deepen the exploration of J.E.’s self-concept and values.

2. Encourage self-compassion and reduce self-criticism.
3. Identify potential goals for personal growth and change.

Session Summary

J.E. began the session by reflecting on his feelings after the first session. He reported feeling
a sense of relief after sharing his story and acknowledged that he often judges himself
harshly. The therapist used empathetic responses to help J.E. explore his self-critical thoughts
and their origins. J.E. discussed his desire to rebuild relationships with his family, particularly
his children, whom he had neglected due to his substance use and antisocial behaviors. He
expressed guilt and shame about his past actions but also a growing sense of responsibility to
make amends. The therapist encouraged J.E. to practice self-compassion and view himself as
a work in progress rather than a failure. J.E. was also guided to identify small, achievable
goals, such as reducing his substance use and reconnecting with his children.

Client’s Response

J.E. appeared more hopeful and motivated. He expressed a willingness to take small steps
toward change and acknowledged the importance of self-compassion.

Therapist’s Observations

J.E.’s affect was brighter, and he demonstrated increased self-awareness. He spoke more
openly about his emotions and showed a willingness to engage in the therapeutic process.

Plan for Next Session

1. Continue fostering self-compassion and self-awareness.

2. Explore strategies for reducing substance use and rebuilding relationships.
3. Reinforce J.E.’s sense of agency and hope.

Clinical Report for Person-Centered Therapy (PCT) Session 3

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Explore J.E.’s progress toward his goals.

2. Address barriers to change and reinforce self-efficacy.
3. Encourage emotional expression and self-reflection.

Session Summary

J.E. reported making small but meaningful progress since the last session. He had reduced his
substance use and reached out to his children via phone. He described feeling a sense of pride
and accomplishment, which the therapist reinforced. The session focused on addressing J.E.’s
feelings of guilt and shame, which he identified as barriers to change. The therapist used
reflective listening to help J.E. process these emotions and reframe them as opportunities for
growth rather than sources of self-punishment. J.E. also discussed his struggles with
impulsivity and aggression. The therapist encouraged him to explore healthier ways of
managing anger and frustration, such as mindfulness and relaxation techniques.

Client’s Response

J.E. appeared more confident and optimistic. He expressed a renewed sense of purpose and
commitment to change.

Therapist’s Observations

J.E.’s mood was euthymic, and his affect was more congruent with his verbal expressions. He
demonstrated increased insight and self-efficacy.

Plan for Next Session

1. Continue addressing barriers to change.

2. Explore strategies for managing impulsivity and aggression.
3. Reinforce J.E.’s progress and self-efficacy.

Clinical Report for Person-Centered Therapy (PCT) Session 4

Date of Session

Duration of Session: 1 hour

Session Objectives

1. Review J.E.’s progress and reinforce positive changes.

2. Deepen the exploration of his values and goals.
3. Encourage emotional expression and self-reflection.

Session Summary

J.E. reported continued progress in reducing his substance use and rebuilding relationships
with his family. He described feeling more connected to his values and goals, particularly his
desire to be a better father. The session focused on exploring J.E.’s values and how they
aligned with his behaviors. The therapist used empathetic responses to help J.E. identify
discrepancies between his actions and values, as well as strategies for aligning them. J.E. also
discussed his plans for the future, including finding stable employment and maintaining
sobriety. The therapist encouraged him to take small, manageable steps toward these goals
and reinforced his sense of agency.

Client’s Response

J.E. appeared more confident and hopeful. He expressed gratitude for the therapist’s support
and acknowledged the progress he had made.

Therapist’s Observations

J.E.’s affect was bright, and he demonstrated increased insight and self-awareness. He spoke
more openly about his emotions and showed a strong commitment to change.

Plan for Next Session

1. Review progress and address any remaining challenges.

2. Prepare for termination and develop a relapse prevention plan.
3. Reinforce J.E.’s sense of self-efficacy and hope.

Clinical Report for Person-Centered Therapy (PCT) Session 5 (Termination Session)

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review J.E.’s progress and reinforce positive changes.

2. Develop a relapse prevention plan.
3. Prepare for termination and foster a sense of closure.

Session Summary

J.E. reported significant progress since the start of therapy. He had reduced his substance use,
reconnected with his family, and taken steps toward finding stable employment. He described
feeling more in control of his life and optimistic about the future. The session focused on
reviewing J.E.’s progress and reinforcing the skills and insights he had gained. The therapist
and J.E. collaboratively developed a relapse prevention plan, which included identifying
triggers, maintaining healthy coping strategies, and seeking support when needed. The
therapist emphasized the importance of self-compassion and encouraged J.E. to continue
practicing the skills he had learned. J.E. expressed gratitude for the therapy and stated that he
felt equipped to manage his emotions and behaviors independently.

Client’s Response

J.E. appeared confident and optimistic. He expressed a sense of closure and readiness to
move forward.

Therapist’s Observations

J.E.’s affect was bright, and his speech was clear and confident. He demonstrated significant
improvement in all areas of functioning and showed a strong understanding of the skills
learned in therapy.

Termination

Therapy was terminated with a plan for follow-up if needed. J.E. was encouraged to continue
practicing the skills learned in therapy and to reach out for support if he experienced any
setbacks.

Overall Progress:

J.E. showed significant reduction in his initial presenting complaints, including substance
use, impulsivity, and aggression. He demonstrated improved self-awareness, self-compassion,
and a strong commitment to change. Therapy was successful in helping him regain a sense of
control and purpose in his life
 CASE REPORT USING ACCEPTANCE AND COMMITMENT THERAPY (ACT)

S. O is a 24-year-old single Nigerian male. He is of athlete build, a bit tall, dark in

complexion with no visible abnormalities or tattoos. He was referred to the department for
individual Psychotherapy (Acceptance and commitment therapy).

BIO DATA

Name: S. O

Age: 24 years

Religion: Christian

Tribe: Yoruba

State: Ogun State

Occupation: House Keeper in a hotel

Address: undisclosed

Source of Referral: Dr Odemuyiwa

Reason for referral: Psychotherapy

Source of Information: Client

Date:

PRESENTING COMPLAINT

Sleeping difficulties, increased appetite, weight gain, reported being aggressive but the drug
he is taking helps him control his aggressive tendencies. Hearing of voices of unseen people
and seeing of things that are not there in clear sensorium (auditory/visual hallucinations),
memory loss and detachment from interpersonal relationships.

HISTORY OF PRESENTING COMPLAINT

Client reported having sleeping difficulties for over 4 months plus. He also reported he only
sleeps well when he takes his recommended drugs. He also reported that he couldn’t recall
when his increased appetite began, but he claimed it has been for a while now. He claimed
that people tell him that he has added weight significantly. When asked about the aggression,
client reported that he couldn’t recall when it started but he knows he has been aggressive for
a long time now. He also reported that his drugs help suppress his aggressive tendencies and
without it, his temper is all over the place. Client also reported being unable to recall certain
information.

FAMILY HISTORY

Client comes from a polygamous family. He reported that the father has 3 wives. Client
reports being the 3rd child of five children from his direct mother. However, he reports that
they are 11 children in total.

Client’s Father: Mr K. S. is a 73 years old Printer, who owns his own printing services
workshop located in Iligbo, Ogun State. Client reported that his father occasionally drinks
alcohol, however he reports no history of mental illness for the father. He is however
asthmatic.

Client’s Mother: R.S is a 53 years old trader who hawks her merchandise. Client reported
being close with the mother. He reports having a healthy/cordial relationship with the mother.
He reports that his mother has no history of substance use and mental illness.

Client’s direct siblings

1st Child: F. S is a 27years old married female who works in a hotel as one of the cleaners.
Client reported that the sister works in the same hotel that he works in. client reported that he
has a healthy relationship with the sister. He reports no history of drug-use/mental illness.

2nd Child: A. S is a 26years old male student of mass communication in National Open
University (NOUN), Abeokuta. Client reports having a cordial relationship with his brother.
He reports that his brother takes substances like alcohol and smoking as well. However, he
reports having knowledge of this based on what he heard from people. Client reported having
seen his brother take alcohol. He reports that his brother has no history with mental illness,
however his asthmatic.

4th Child: J. S is a 20years old male fuel attendant in a fuel station (petrol station) with SSCE
as his highest Educational Qualification. Client reports that the brother occasionally drinks
alcohol. Client reported that he has no history of drugs and mental illness.
5th Child: O. S is a 14 years old student of SS1 in Baptist Girls College Ogun State. Client
reported not having a god relationship with his sister. He also reported that she is afraid of
him (Client). However, client reported making efforts to have a close relationship with the
sister and he likes her as well. He reported that the sister has no history of substance use/drug
use and mental illness.

PERSONAL HISTORY

Client was born on 20th April 1997. He reported that his mother’s pregnancy was full term.
Client reported that the birth process was through the normal process (Spontaneous Vaginal
Delivery). He reported not having any other information surrounding birth. He reports that
his developmental milestones were within the normal range. He also reported starting school
at the normal age, but he can’t really recall the information.

EDUCATIONAL HISTORY

Client reported that he couldn’t recall his age when he attended kindergarten. However, the
name of the school is Oba Solomon Nursery and Primary School, Ogun State. He reported
attending the school till primary 4 when he decided to change school to Baptist Primary
School Ogun State where he completed his primary school education. He reported that he
believes that the change of school was financially related, although his parents didn’t give
him that information. He reported completing Primary School at the year 2008. Client
reported having a good experience in primary school. He has good grades, however his
association with his fellow students was poor. In 2008, client got enrolled into Lisabi
grammar school for his Secondary education where he completed his secondary education
and got his SSCE certificate. He reported that his association with his fellow classmates were
poor back then. However he reports having improved with the way he relates with people.
Currently client is not enrolled in any institution.

OCCUPATIONAL HISTORY

In the year 2014, client reported learning to be a barber in a barbing saloon. Client reported
that this lasted over 3 years, however client reported quitting the work because he realized
wasn’t good at it. However, he also reported having passion for the work but practicing it was
difficult for him. Client reported working as a security officer at Proton Security Services
Ogun State. He reported having a respectful relationship with his co-workers and bosses. He
also reported working there for a maximum of 1 year and few months.
Client reported getting a job at Obasanjo Presidential Library Ogun State. However this was
during the onset of his Psychological problem which led to him quitting the job and being
admitted into the Psychiatric hospital. However, the client reports not being able to recall the
particular year, but he knows someone that can help with the information. After his discharge
from the hospital, client reported working in IBD hotel Ogun State for a period of 3months
plus as a cleaner. He reported that he got promoted to house cleaning within that work period.
Client reported having a respectful relationship with his co-workers and bosses.

Currently client reports working in M4 hotel leme Ogun state as house keeper. For a period of
5 months now. Client reported his work experience to be very good. He reported not having
the zeal for interpersonal relationship which was also reported to the doctors. He reported
feeling this way to his co-workers. However he reports having a respectful relationship with
his bosses

PSYCHOSEXUAL HISTORY

Client identifies as male. He reported attaining puberty at 17 years of age. Client reported not
having any sexual experience (intercourse). He claimed it was against his faith. He reported
making the decision to hold on until marriage. Client reported that he has had relationships in
the past but presently he is not in any relationship. Client is not married.

DRUG HISTORY

Nil

FORENSIC HISTORY

Nil

PREMORBID PERSONALITY

C = cheerful, resilient

H = reported not being comfortable disclosing the information

A = proactive, optimistic, positive minded

R = takes his faith serious, very religious

M = elated. Euphoric

MENTAL STATUS EXAMINATION

Appearance and behaviour: client is a bit tall, dark in complexion with no visible
abnormalities, tattoos or bodily marks. On presentation, client wore wine-red trousers with a
blue, white and red striped polo t-shirt, and a black pam slippers. Client appeared neat and
well-groomed with properly dressed hair. Client was calm and maintained good eye contact.
Client was cooperative during the course of history taking.

Speech: Speech is coherent, volume is normal, rate is moderate and speech is fluent.

Mood: Euthymic

Affect: Appropriate

Thought process: Normal, No signs of hallucinations.

COGNITION

Orientation: client is properly oriented to time, person and place.

Attention: non distractible

Concentration: Focused

Insight: good

Judgement: fair

TEST ADMINISTERED

1. ISBC (incomplete sentence blank college form)

2. DAP (Draw a person test)
3. MMPI (Minnesota Multiphasic Personality Inventory)

TEST TAKING BEHAVIOUR

Client was calm, cooperative well concentrated and showed no sign of restlessness
throughout the test taking process.

TEST RESULT

1. ISBC: client’s ISBC result suggests:

Religious (items 1, 3, 27)
Possible depression (items 2, 5, 10, 20, 24, 28, 34)
Worry (items 13, 33)
Trust issues (items 5, 10, 29)
 Insightful (25)
2. DAP: Client’s DAP suggests: active aggressive role in the environment, need for strength
and power, strong security needs, immaturity, regression, primitive aggressive tendency
associated with paranoid processes, psychosomatic disorder and hypertensiveness,
uneasiness over fantasy life, excessive sexuality and sensuality as occasionally seen in
adolescents, feelings of inadequacy, possible castration feelings, organicity, possible
psychosis, uneasy in social situations; guilt feelings, possible dishonesty, possible
schizoid tendency, possibility of schizophrenia, feelings that environment is too limiting,
with dependency, indecisive regarding desire for independence, possible impulsivity,
problems in social effectiveness, possible need to punish self for masturbation, possible
parental identification. Possible striving to achieve self-control and immaturity, possible
regression.
3. MMPI: on the validity scale, client had a VRIN and TRIN t-score of 69 and 79
respectively. This indicate that profile is valid
On the frequency scale F, F B and FP, client had a t-score of 116, 116 & 106 respectively.
This indicate that profile might be invalid.
On the defensive scale L. K & S, t-score of 65, 33 & 40 were obtained respectively. L
scale and K scale indicate that profile may be invalid. On the S scale, profile is valid.
On the clinical scales, client had elevations on scale 1, 2, 6, 7, 8 and 0 with a t-score of
68, 66, 79, 74, 91 and 68 respectively. The configuration of the clinical scales puts client’s
code type at 6-8/8-6 personality code type. This is characterised by:
Intense feelings of inferiority and insecurity; lack of self-confidence and self-esteem; fels
guilty about perceived failures, withdrawal from activity, emotional apathy; suicidal
ideation, not involved with other people, suspicious and distrustful; avoids deep
emotional ties, deficient in social skills; most comfortable when alone; resents demands
placed on him/her, moody, irritable, unfriendly, negativistic, schizoid lifestyle.
Usually diagnosed as schizophrenia, paranoid type (especially if both scales are very
elevated and higher than scale 7). Clearly psychotic behaviour may be present; thinking is
autistic fragmented tangented and circumstantial; bizarre thought content; difficulties in
concentrating, attention, memory; poor judgment, delusion of persecution and/or
grandeur; feelings of unreality, preoccupied with abstract or theoretical matters to
exclusion of specific aspects of life situations; blunted affect; rapid and incoherent
speech; lacks effective defensive; reacts to stress and pressure by withdrawing into
fantasy and day dreaming; may have difficulty differentiating between fantasy and reality.
IMPRESSION

The personality profile indicates a schizotypal personality disorder. Diagnosis was based on
case history, test results and clinical observation in accordance with DSM-V

Psychological treatment suggests

1. Acceptance and commitment Therapy

Clinical Report for Acceptance and Commitment Therapy (ACT) Session 1

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Establish rapport and introduce the client to the principles of ACT.

2. Explore the client’s presenting complaints and their impact on his life.
3. Begin identifying values and committed actions aligned with those values.

Session Summary

The session began with the therapist explaining the core principles of ACT, including
acceptance, cognitive defusion, values, and committed action. The client S. O appeared calm
and cooperative but initially hesitant to engage deeply. The therapist used open-ended
questions to explore Shondei’s presenting complaints, including his sleeping difficulties,
aggression, hallucinations, and interpersonal detachment. Client expressed frustration with
his inability to control his aggressive tendencies and his feelings of isolation. He also shared
his struggles with auditory and visual hallucinations, which he described as distressing and
confusing. The therapist validated his experiences and introduced the concept of acceptance,
encouraging S.O to observe his thoughts and feelings without judgment. The session
concluded with a discussion of client’s values. He identified family, faith, and personal
growth as important to him. The therapist encouraged him to reflect on small, actionable
steps he could take to align his behavior with these values.

Client’s Response

S.O appeared thoughtful and engaged. He expressed curiosity about ACT and a willingness to
explore new ways of managing his symptoms.
Therapist’s Observations

Client’s mood was euthymic, and his affect was appropriate. He demonstrated good insight
into his challenges but struggled with self-compassion.

Plan for Next Session

1. Continue exploring client’s values and identifying committed actions.

2. Introduce cognitive defusion techniques to help him manage distressing thoughts.
3. Foster a sense of self-compassion and acceptance.

Clinical Report for Acceptance and Commitment Therapy (ACT) Session 2

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review client’s progress and reinforce the principles of ACT.

2. Introduce cognitive defusion techniques to manage distressing thoughts and
hallucinations.
3. Continue exploring values and committed actions.

Session Summary

S.O reported slight improvements in his mood and a reduction in aggressive tendencies since
the last session. He acknowledged that his hallucinations were still present but felt less
overwhelmed by them. The therapist introduced cognitive defusion techniques, such as
labeling thoughts (e.g., “I am having the thought that I am hearing voices”) and visualizing
thoughts as passing clouds. S.O practiced these techniques in session and reported feeling a
sense of relief. The therapist also encouraged him to use these techniques when experiencing
distressing thoughts or hallucinations. The session continued to explore client’s values,
particularly his desire to improve his relationships with his family and colleagues. He
identified specific actions, such as initiating conversations with his sister and expressing
gratitude to his coworkers, as steps toward aligning his behavior with his values.

Client’s Response
S.O appeared more hopeful and engaged. He expressed a willingness to practice cognitive
defusion techniques and take small steps toward his values.

Therapist’s Observations

Client’s affect was brighter, and he demonstrated increased self-awareness. He showed a

growing ability to observe his thoughts without judgment.

Plan for Next Session

1. Review the effectiveness of cognitive defusion techniques.

2. Explore barriers to committed actions and address any challenges.
3. Introduce mindfulness exercises to enhance present-moment awareness.

Clinical Report for Acceptance and Commitment Therapy (ACT) Session 3

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review client’s progress and reinforce the use of ACT techniques.

2. Introduce mindfulness exercises to enhance present-moment awareness.
3. Continue exploring values and committed actions.

Session Summary

S.O reported continued progress in managing his aggressive tendencies and hallucinations.
He described using cognitive defusion techniques effectively and feeling more in control of
his thoughts. The therapist introduced mindfulness exercises, such as mindful breathing and
body scans, to help S.O stay grounded in the present moment. S.O practiced these exercises
in session and reported feeling calmer and more focused. The therapist encouraged him to
incorporate mindfulness into his daily routine, particularly during moments of stress or
distress. The session also focused on client’s values related to faith and personal growth. He
identified attending religious services and setting small personal goals as committed actions.
The therapist reinforced the importance of taking small, manageable steps toward these goals.
Client’s Response: S.O appeared more confident and optimistic. He expressed a sense of
empowerment and gratitude for the progress he had made.
Therapist’s Observations

Client’s mood was euthymic, and his affect was congruent with his verbal expressions. He
demonstrated increased self-efficacy and a growing ability to stay present.

Plan for Next Session

1. Review the effectiveness of mindfulness exercises.

2. Address any remaining barriers to committed actions.
3. Prepare for termination and develop a relapse prevention plan.

Clinical Report for Acceptance and Commitment Therapy (ACT) Session 4

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review client’s progress and reinforce the use of ACT techniques.

2. Address any remaining challenges and barriers to change.
3. Begin preparing for termination and develop a relapse prevention plan.

Session Summary

S.O reported significant improvements in his mood, aggression, and ability to manage
hallucinations. He described feeling more connected to his values and taking consistent steps
toward his goals. The therapist praised his efforts and reinforced the importance of continued
practice. The session focused on addressing any remaining challenges, such as client’s
occasional feelings of isolation and self-doubt. The therapist encouraged him to use ACT
techniques, such as cognitive defusion and mindfulness, to manage these challenges. The
therapist and S.O collaboratively developed a relapse prevention plan, which included
identifying triggers, maintaining mindfulness practices, and seeking support when needed.
S.O expressed confidence in his ability to manage his symptoms independently.

Client’s Response

S.O appeared confident and optimistic. He expressed gratitude for the therapy and a sense of
readiness to move forward.
Therapist’s Observations

client’s affect was bright, and his speech was clear and confident. He demonstrated
significant improvement in all areas of functioning and showed a strong understanding of the
skills learned in therapy.

Plan for Next Session:

1. Review the relapse prevention plan and address any final concerns.
2. Foster a sense of closure and celebrate client’s progress.

Clinical Report for Acceptance and Commitment Therapy (ACT) Session 5

(Termination Session)

Date of Session:

Duration of Session: 1 hour

Session Objectives

1. Review client’s progress and reinforce the skills learned in therapy.

2. Finalize the relapse prevention plan.
3. Foster a sense of closure and celebrate client’s achievements.

Session Summary:

S.O reported continued progress and a significant reduction in his initial presenting
complaints. He described feeling more in control of his emotions, more connected to his
values, and more confident in his ability to manage his symptoms. The therapist reviewed the
relapse prevention plan and reinforced the importance of continued practice.

The session concluded with a celebration of Client’s achievements. The therapist emphasized
his inherent worth and capacity for growth, and S.O expressed gratitude for the therapy and
the progress he had made.

Client’s Response

S.O appeared confident and optimistic. He expressed a sense of closure and readiness to
move forward.

Therapist’s Observations
Client’s affect was bright, and his speech was clear and confident. He demonstrated
significant improvement in all areas of functioning and showed a strong understanding of the
skills learned in therapy.

Termination

Therapy was terminated with a plan for follow-up if needed. S.O was encouraged to continue
practicing the skills learned in therapy and to reach out for support if he experienced any
setbacks.

Overall Progress

S.O showed significant reduction in his initial presenting complaints, including aggression,
hallucinations, and interpersonal detachment. He demonstrated improved self-awareness,
emotional regulation, and a strong commitment to his values. Therapy was successful in
helping him regain a sense of control and purpose in his life