Identifying Data
Name H.T
Age 24 years
Gender Male
Education Graduation
No. of siblings 3
Birth order 2nd
Religion Islam
Informant Client and his brother
No. of session 4
Presenting Complaints
H.T is a 24 years old male who presents complaints of insomnia, fatigue and pain in body and craving to use opioids.
Initial Observation
During the initial meeting, the client presented in a way that was appropriate for both the season and the setting. Overall, he maintained adequate hygiene and combed his hair neatly, which indicated a basic level of self-care. However, I also observed a few notable physical signs: his skin appeared quite pale, and his lips were dry with a purplish tint. While his height seemed appropriate for his age, he did look underweight.
He showed limited facial expressions, which conveyed a restricted affect. He appeared somewhat irritated, though he described his mood as normal. Eye contact was inconsistent—maintained at times, but not throughout the session.
He spoke softly but with strength, showing no signs of limited vocabulary or language delay. He sat comfortably throughout the session and showed no signs of inappropriate physical behavior. The client engaged spontaneously and responded to most questions, though he remained quiet at times. There were moments of defensiveness, which created some initial challenges in building rapport—but not uncommon during early interactions.
Overall, the session offered a valuable first look at the client’s presentation, giving insight into both his physical and emotional state, and setting the stage for future therapeutic work.
History of Present Illness
The client’s story began in 2022, at the age of 20—a turning point that would mark the beginning of a long and difficult battle with substance use. It all started at a party with friends, a seemingly harmless night out that quickly spiraled into something far more serious. That night, surrounded by peer pressure and easy access, he tried hash for the first time. He recalls smoking around 2–3.5 grams—equivalent to nearly 14–15 cigarettes. The high was intense. For the first time, he felt free of all his problems, floating in a world where everything felt light, euphoric, and carefree.
Naturally, he wanted to feel that way again. Just a couple of days later, he returned to the party, convinced his friends to come along, and once again got high. It felt like the “best feeling in the world.” That night, he connected with a dealer, and for the next two years, he regularly used hash.
His mother began to notice changes—he was coming home late, behaving differently—but when she confronted him, he denied everything. The warning signs were there, but they weren’t fully understood or addressed at the time.
In 2024, things took another emotional turn. He was in a relationship with someone he genuinely loved. She knew about his drug use and pleaded with him to stop. He lied, telling her he had quit. But lies can’t hold up forever. When she discovered the truth, she ended the relationship and cut off all contact. The breakup hit him hard. In a state of anger and emotional chaos, he drank alcohol for the first time—two glasses mixed with water—at a friend’s place. Fueled by rage and intoxication, he stormed over to his ex-girlfriend’s home and caused a major scene, physically fighting with her brother and father. Her father later confronted the client’s father, saying, “Like father, like son,” a painful reminder of the father’s own history with alcohol.
From there, things deteriorated rapidly. The client began drinking regularly. He came home intoxicated, often clashing with his family—particularly his mother and brother. His father stopped speaking to him entirely. Anger became his default state. He was easily triggered, and minor disagreements often led to explosive arguments. The household atmosphere grew increasingly tense and stressful.
His behavior also turned desperate—stealing money from his mother and brother to fund his drinking. Academically, he was struggling; he dropped out of his B.Com program due to lack of focus and interest.
Then came the next, even darker chapter. By the end of 2024, he had been introduced to heroin. What started as occasional sniffing quickly escalated into full-blown addiction. At first, it was small doses—but he was consuming up to 2.5 grams daily. He admitted that he couldn’t function without it. The moment the effects wore off, the cravings returned with full force.
Then, he attempted to quit. Withdrawal hit him hard, causing intense body aches, restlessness, and a sensation he described as ‘being beaten.’ The discomfort pushed him right back into using. His tolerance grew, and by the end of the year, his intake reached 3 grams per day.
Additionally, things hit rock bottom. He stole his father’s credit card to buy heroin. The family confronted him, thinking he only drank. He exploded in anger and admitted his heroin addiction. The truth shattered the family. His mother was inconsolable, blaming herself for not intervening sooner. His father got disappointed. The emotional toll on the entire household was immense.
It was his brother who finally stepped in, urging him to seek professional help. After persistent efforts and heartfelt conversations, the client agreed and was ready to begin the long road to recovery.
Family History
Behind every story of addiction is a network of relationships—some strained, some supportive—that shape the journey toward healing. In the case of this client, family plays a deeply significant role.
Relation with parents
The client’s father, now 60, holds a Bachelor’s degree and runs his own business. Their relationship was once warm and respectful. However, things changed drastically when the father discovered his son’s drug use. Since then, their bond has become tense and distant. Adding complexity to the situation, the father struggles with alcoholism himself and also suffers from a heart condition and depression—creating a layered dynamic of generational patterns and unresolved emotional pain.
The client’s mother, 55, is a homemaker with an educational background up to Matric. She remains emotionally connected and deeply concerned for her son. Her relationship with him is nurturing, and she frequently urges him to leave drugs behind, driven by the fear that he might follow in his father’s footsteps. Her love is evident, but so is the weight she carries—watching her son fight a battle she feels powerless to stop.
Relation with siblings
The client is the second of four siblings. His elder brother, who holds an MBA and works at a bank, has been a steady pillar of support. Their bond is strong, and it was ultimately his brother’s encouragement and persistence that led the client to seek help. He recognized that behind his brother’s firm stance was genuine care and hope for a better future.
One of his sisters, aged 21, is married and currently living in Islamabad. Despite the physical distance, their relationship remains close and positive. His youngest sister, 18, is pursuing her intermediate studies, and like the others, shares a congenial and supportive connection with the client.
In many ways, his family reflects a mix of love, concern, and struggle—a reminder that addiction doesn’t just affect the individual, but sends ripples through the entire family system. Yet, it’s also clear that while the road has been difficult, the foundation of support is still there, ready to hold space for healing.
Personal History
The client’s early life paints the picture of a fairly typical childhood—one without major disruptions or red flags. Born through a normal delivery, he met all his developmental milestones right on time. His childhood was free from traumatic events, and there were no signs of unstable behaviors or psychological concerns during those formative years.
Physically, he was a healthy child with no significant medical or psychiatric issues. His personality was naturally outgoing—active, curious, and sociable. He enjoyed the simple pleasures of childhood, spending much of his free time either watching television or playing games, both indoors and out.
Academically, he was an average student, never particularly high-achieving, but steady. In terms of behavior, he was respectful and compliant—he followed the rules, listened to his parents, and showed a natural deference to authority figures.
Looking back, his early years were stable and uneventful in the best way. It’s a reminder that addiction doesn’t always stem from early trauma—sometimes, it finds its way into even the most ordinary beginnings.
Education History
The client completed his intermediate education and was pursuing a B.com when he realized he couldn’t function properly without drugs, so he quit his studies. He was an average student throughout his life. He got his education from a renowned college and school. There, he made many friends at that time. Moreover, he was jolly in nature, and his behavior at school was good. All the teachers appreciated his behavior. And, there was no history of bullying or truancy.
Occupational History
After completing his Intermediate education, the client joined his father’s business, stepping into the world of work for the first time. While it seemed like a logical next step, he quickly found the daily routine to be repetitive and uninspiring. The work lacked the variety and challenge he was looking for, and boredom began to set in.
Recognizing that the path wasn’t fulfilling, he made the decision to step away from the business and enrolled in a B.com program instead—hoping that a return to academics might open up new opportunities and a clearer direction for his future.
Premorbid Personality
Before addiction took hold, the client came across as a vibrant and outgoing individual. He naturally sought out social settings and surrounded himself with friends, enjoying being around people. So, social gatherings, casual hangouts, and spending time watching TV filled most of his leisure hours. He thrived on connection and rarely spent time alone by choice.
His general mood was upbeat—happy, energetic, and full of life. While he had a strong personality and appeared emotionally resilient on the surface, stressful situations often left him feeling overwhelmed. Coping with stress wasn’t his strong suit, and he admitted that frustration would build quickly when things didn’t go as expected.
One notable aspect of his personality was his impulse control. In his earlier years, he was able to manage his impulses well. But over time—especially with the onset of drug use—that control gradually slipped away. Despite making repeated promises to quit, he often found himself giving in, unable to resist the cravings.
He didn’t actively engage in religious practices, and spirituality never played a defining role in his identity.
Looking back, he was someone full of potential—socially active, emotionally expressive, and filled with a natural zest for life. The changes that followed make his story all the more complex and deeply human.
Psychological Assessment
Formal and informal assessment was done:
- Clinical interview
- Mental Status Examination
- Subjective Rating of symptoms
- Drug Abuse Screening Test (DAST)
- Anger and Expression Scale
Case Formulation
At just 24 years old, a young man found himself referred for psychological assessment and support. He struggled with sleepless nights and chronic fatigue. He also experienced physical pain, persistent irritability, anger outbursts, and a strong craving for drugs. All signs pointed toward a more complex issue beneath the surface.
According to the DSM-5, opioid use disorder isn’t just about drug consumption — it includes an intense craving or urge to use opioids, often at the cost of one’s social, occupational, and recreational life. This young man’s story echoed that definition clearly. He reported frequent cravings and admitted that his family relationships were deteriorating — aggression and abusive language had become common at home. And, Isolation replaced once joyful family moments, as he spent most of his time either with friends or seeking out heroin.
The Family Link: A Generational Struggle
The client’s background revealed more than just a personal struggle — it hinted at a generational pattern. His father had a history of alcohol use and ongoing depression. Research backs this up: children of substance-abusing parents are over twice as likely to develop substance use disorders themselves.. Parental mental health issues, particularly depression and anxiety, can contribute to maladjustment in children, making them more vulnerable to substance abuse.
In this case, the client’s father, who was battling depression, often disengaged and paid little attention—especially when the young man returned home late. There was little emotional connection or guidance. According to studies, depressed parents may struggle to show warmth, and their parenting may swing between neglect and intrusiveness. It’s no surprise that children raised in such environments may later struggle with emotional regulation and turn to substances as a coping mechanism.
Unmet Needs and the Search for Belonging
From a psychodynamic perspective, individuals who struggle with substance use often have unmet emotional needs stemming from early life. So, the young man felt emotionally abandoned and said he had no one at home he felt safe talking to. His friends became his support system, but unfortunately, they introduced him to drugs. Over time, the fleeting comfort of opioids replaced the comfort he never received at home.
The Vicious Cycle of Temporary Relief
Cognitive-behavioral theory explains how substances like opioids can become crutches. Initially, they offer temporary relief from stress or emotional pain. Over time, this reinforces the belief that drugs are the only way to cope — especially in times of distress. For this client, what started as a way to manage tension quickly spiraled into tolerance and dependency.
From a behavioral lens, drug use becomes part of a person’s daily routine when it consistently brings short-term rewards. The client recalled his first experience with hash as enjoyable — and that pleasure was enough to make him want it again. It’s classic reinforcement: feel good once, seek it again.
A Glimmer of Hope: Family Motivation
Despite the challenges, one thing stands out — his family still cares. While their previous approach may have been lacking, they are now actively encouraging him to seek help. This support, though late, could be a crucial factor in his recovery.
Looking Deeper: A Profile of Vulnerability
In summary, the assessment pointed to a young man with deep-rooted emotional insecurities, poor stress management, and a history of emotional deprivation. These factors didn’t just make him vulnerable — they set the stage for substance abuse to take hold.
His journey is a stark reminder that addiction isn’t just about the drugs. It’s about the environment, emotional wounds, family patterns, and the lack of healthier coping tools. However, the right support, awareness, and intervention can break the cycle
Management Plan
Short-term goals
- Structured individual sessions will be introduced.
- Supportive therapy will be given to client to build up rapport with the client.
- Client will be psych educated about his illness.
- Activity scheduling will be given to keep him busy in ward
- Relaxation exercises will be used to keep him relax and to improve his sleep.
- 16 PMR will be done with the client to make him feel at ease and to manage his somatic symptoms.
- Vicious cycle will be explained to the client to make him develop a better understanding of his problems.
- Aversion therapy involves pairing aversive stimuli to cognitive images of opioid use and conversely conjuring images of socially appropriate behaviors such as employment, education, and nondrug behavior.
- Cost benefit analysis will be done with the client such as benefit of leaving or taking drugs.
- Sleep hygiene will be taught to the client to deal with his sleep disturbance.
- Assertive training will be taught to the client, so that he learns to refuse the drugs offered to him in future.
- Eliciting Negative Automatic Thoughts (NATs) will be done to make him aware of his thoughts.
- Triple column technique
- Thought stopping technique will be done to help the client in stop thinking of drugs.
- Self-monitoring will be taught to the client so that he would be able to identify his thoughts and would know how to stop them.
- Craving management will be done to make sure that the client knows how to deal with it in future.
- Anger thermometer
- Examining the evidence and counter evidence
- Distraction
- Mastery and pleasure exercise will be done with the client so that he develops pleasure in activities beside drugs.
- Positive self-coping statements will be created so that he would be aware how to cope up with the situations where he would need drugs.
- Relapse prevention will be done to prevent future relapse.
Long-term goals
- Stress management training will be given to deal effectively with any stressful situation in future.
- Maintenance of follow up sessions.
