UNIVERSITI TEKNOLOGI MALAYSIA

PUSAT PENGAJIAN JOHOR BAHRU

PAIRING ASSIGNMENT
CASE STUDY REPORT

A CASE STUDY OF SCHIZOPHRENIA WITH AUDITORY

HALLUCINATIONS (VOICES)

SHMY 1023
INTRODUCTION TO COUNSELING

NAME STUDENT ID

HAZARA NAZ BINTI MOHD ASLAM SX230822HMYHS01

RAMULAMA A/P SIVARAO SX222043HMYHF01

LECTURER:
DR FARAH ADIBAH BINTI IBRAHIM
 TABLE OF CONTENTS

1.0 INTRODUCTION………………………………………………………………………………………..3

2.0 PROBLEMS………………………………………………………………………………………………5

3.0 COUNSELING PROCESS………………………………………………………………………………8

4.0 CONCLUSION…………………………………………………………………………………………..12

5.0 REFLECTION…………………………………………………………………………………………...13

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 Case Study Report

Schizophrenia : A case study of Mr Raj with Schizophrenia with Auditory Hallucinations (Voices)

1.0 Introduction

Schizophrenia is a complex and severe mental disorder that affects approximately 1% of the global
population, transcending cultural, social, and economic boundaries. It is characterized by a wide array of
symptoms that often present challenges in daily functioning. Individuals diagnosed with schizophrenia
typically experience disruptions in thought processes, emotions, perceptions, and behaviors.

The hallmark symptoms of schizophrenia can be categorized into three main groups:

1. Positive Symptoms

These symptoms involve changes in thoughts and behaviors that are not typically experienced by the general
population. They include hallucinations (auditory, visual, etc.), delusions (false beliefs often resistant to
contrary evidence), disorganized thinking, and abnormal motor behavior.

2. Negative Symptoms

These refer to a reduction or absence of certain normal functions and behaviors. They include reduced
emotional expression, diminished motivation or pleasure in daily activities (avolition), decreased speech
(alogia), and social withdrawal.

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 3.Cognitive Symptoms

Schizophrenia can also affect cognitive abilities, impairing memory, attention, and the ability to process
information effectively. Individuals may struggle with decision-making, organizing thoughts, and focusing
on tasks.

The challenges posed by schizophrenia are multifaceted, impacting various aspects of an individual's life.
These challenges often lead to difficulties in maintaining relationships, pursuing education or employment
opportunities, and managing day-to-day responsibilities. The symptoms can cause distress not only for the
individual but also for their family members and caregivers.

Connecting this with the case study, the client presented in the study is a 41-year-old male diagnosed with
paranoid schizophrenia. He experienced auditory hallucinations and other symptoms, leading to decreased
interaction, changes in behavior, increased anger, and religious preoccupation. His gradual onset of illness
over 18 years impacted his ability to maintain employment, engage in daily tasks, and maintain social
relationships. The study aimed to assess and intervene in various aspects of his life, including family
dynamics, coping strategies, and cognitive behavioral therapy to manage his auditory hallucinations and
overall symptoms of schizophrenia. The case study exemplifies the challenges faced by individuals
diagnosed with schizophrenia and the multifaceted approach required to address their needs
comprehensively.

Objective/Aim
The objective of this case study is to conduct a detailed assessment of Mr. Raj, who’s diagnosed with
paranoid schizophrenia. We also want to examine his background, family dynamics, and the psychosocial
factors that are influencing his mental health. The aim is to contribute with insights into schizophrenia, and
the psychological factors contributing to the disorder. Along with highlighting interventions and advancing
our understanding for schizophrenia and treatment options.

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2.0 Problems

The 41-year-old male index client was of Hindu descent, single, and from a lower middle socioeconomic
background. He was a native of Dhemaji, in the District of Assam. The patient was admitted to the
Lokopriya Gopinath Bordoloi Regional Institute of Mental Health in Tezpur for psychiatric treatment after
receiving a diagnosis of paranoid schizophrenia. The name of this client will remain anonymous

Source of Information
The data was collected from Mr. Raj, his sister, and his father, in addition to his case file. The collected data
is deemed reliable and adequate for this case study.

Reason for Referral

The case was recommended for an extensive evaluation and intervention of Mr. Raj’s issues related to his
decreased interactions, unusual behavior, increased anger, talking to himself, smiling at odd times, excessive
religious devotion, and decreased need for sleep. His illness has been with him for 18 years, without any
identifiable triggers, notable previous medical conditions or a family history of mental illness.

Brief Clinical History

Mr. Raj’s mental health history indicates a gradual onset of symptoms, such as auditory hallucinations,
eccentric behavior, and heightened irritability. The condition has lasted for a total of 18 years, with no prior
medical conditions or relevancy. During the mental status evaluation, the client demonstrated a neat and tidy
appearance, high amount of productivity, good cognitive function, and anxiousness. Auditory hallucinations
were present, specifically third person, indicating a high level of insight.

Family Tree
His family consisted of his 65-year-old father, a cultivator, along with his 63-year-old illiterate homemaker
mother. Mr. Raj has four siblings, with varying levels of education and marital status. The family dynamics
were characterized by clear boundaries, defined roles, and a process of decision making that is democratic.
Mr. Raj’s interaction with family members was reported as cordial, with emotional attachment mostly to his
mother.

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Personal History
The client, the first among four siblings, had a normal birth and achieved developmental milestones
appropriately. He studied up until his second year of a bachelor degree. He also worked in a Sahara company
for about five years from 2000 to 2005, until he quit due to his illness. Mr. Raj reported average performance
in his studies and normal health during childhood. The premorbid personality assessment indicates a well
adjusted personality.

Psychosocial Formulation
Mr. Raj, aged 40, and unmarried. Belongs to a lower socio economic background in Dhemaji District,
Assam, and was brought to LGBRIMH for treatment. Poor knowledge about mental illness, substance abuse
history, work-related issues, and poor drug compliance contributed to the progression of the illness. His
family lacked the understanding of mental illness necessary, and both positive and negative reinforcements
were observed in the family dynamics. Mr. Raj’s distress was evident, especially considering the high level
of irritability and aggression linked to his auditory hallucinations.

Z56 - Problem related to employment and unemployment

Z72.2 - Problems related to drug use
Z91.1 - Personal history of noncompliance with medical treatment and regimen
The family dynamics assessment using the Family Assessment Device (FAD) revealed challenges in
problem-solving and behavioral control within the family. The client's psychosocial issues were complex,
involving employment problems, substance use, and noncompliance with treatment.

Issues that Mr Raj experienced caused by Schizophrenia disorder:

1. Psychiatric Symptoms

Mr Raj exhibited a range of psychiatric symptoms, including decreased interaction, wonderous behavior,
increased anger, self-muttering, self-smiling, over-religiosity, and reduced need for sleep. These symptoms
were observed consistently, impacting the Mr Raj‘s social functioning and daily activities. For instance, the
Brief Psychiatric Rating Scales (BPRS) administered during the pre-intervention phase recorded specific
details about the intensity and frequency of these symptoms. The BPRS, a widely used tool to assess
psychiatric symptoms, quantified the severity of these behaviors, indicating their presence and impact on the
Mr Raj’s mental state.

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 2. Auditory Hallucinations

Mr Raj experienced distressing 3rd person auditory hallucinations, which significantly affected their ability
to concentrate and engage in daily tasks. These hallucinations were reported consistently and were identified
as a major source of distress for Mr Raj. The Psychotic Symptoms Rating Scales (PSYRATS) provided
detailed assessments of the dimensions of these hallucinations. Pre-intervention scores indicated high levels
of distress, frequency, duration, loudness, and disruption to daily life caused by the auditory hallucinations.
Post-intervention, these scores significantly decreased, indicating the success of the intervention in reducing
the impact of these hallucinations.

3. Family Dynamics

The family demonstrated inadequate knowledge about mental illness, especially schizophrenia, resulting
in suboptimal coping strategies and problem-solving mechanisms. The Family Assessment Device (FAD)
revealed challenges within the family structure, particularly in problem-solving and behavioral control. This
was indicative of a lack of effective strategies to manage Mr Raj's (The Client) condition within the family
unit. Additionally, observations from interviews and assessments highlighted the use of both positive and
negative reinforcement within the family environment, showcasing inconsistencies in responding to the Mr
Raj's symptoms and needs.

4. Poor Insight and Coping

Mr Raj showed limited insight into their condition and struggled with effective coping strategies to
manage the distress caused by auditory hallucinations. Mental status examinations and self-reports
indicated a grade 4 level of ins\ight into the illness, signifying a limited understanding of the condition's
nature and implications. Furthermore, pre-intervention assessments using standardized scales such as the
Hamilton Anxiety Rating Scale (HAM-A) and the Calgary Depression Scale for Schizophrenia highlighted
elevated scores, indicating the presence of anxiety and depression linked to the auditory hallucinations.

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3.0 Counseling Process

Counseling Process

1. The counseling process begins with the establishment of rapport.

Helping, standing up for, and encouraging the clients we work with is our first responsibility. You might be
curious about what your clients who are actively suffering psychosis might want in order to feel supported if
you work with them. The client is the most qualified individual to respond to such a fantastic question. There
are two approaches to get through to a client by asking how you can support them or what you can do to
help. The client must first realize that you are there to assist them and that you want to listen to them.
Second, it fosters trust between you and the client—particularly if this is your first direct questioning of them
as a mental health professional. Therefore, Cultivating a strong connection is essential for achieving
successful therapeutic alliances. The therapist utilized techniques such as reassurance, maintaining a pleasant
demeanor, and ensuring confidentiality to establish a welcoming and trustworthy atmosphere for the client.
Mr Raj was told about the therapy and its potential benefits during the meeting.Mr. Raj was receptive and
prepared to move forward as soon as the therapist gave his introduction to the therapy. The goals of therapy
are to alleviate hallucinations in patients and lessen the discomfort brought on by psychotic symptoms. In
order to further inform Mr. Raj's family members about how to deal with Schizophrenia patients.

2. Analyzing the Issue

The analysis of Mr. Raj’s case required a thorough evaluation that considered both his clinical condition and
socio-demographic factors. A comprehensive assessment was conducted to gather clinical information,
including psychiatric symptoms and treatment history, in order to develop a thorough understanding of his
mental health condition. Furthermore, we examined family dynamics by using the Family Assessment
Device (FAD), a reliable tool that evaluates different aspects such as problem-solving, communication, and
emotional engagement within the family unit.

The mental health assessment included a variety of measures, which helped us gain a detailed understanding
of Mr. Raj's condition. The Brief Psychiatric Rating Scales (BPRS) are a tool used to identify and assess
minor psychiatric symptoms. They provide valuable information about various areas including anxiety,
emotional withdrawal, and hallucinatory behavior. According to the results of the Hamilton Anxiety Rating

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Scale (HAM-A) and The Calgary Depression Scale for Schizophrenia, it was found that there is a mild
presence of anxiety and depression, respectively. The findings revealed that Mr. Raj is facing various mental
health challenges, highlighting the complexity of his situation.

The careful examination provided in this analysis forms the basis for creating a customized and effective
plan to address Mr. Raj's specific psychiatric symptoms and how they are affecting his overall well-being. By
incorporating a range of assessment tools, we can gain a thorough understanding of the problem at hand,
which in turn helps us make informed decisions about the most effective therapeutic approaches to take.

3. Goal Setting

The objectives encompassed the evaluation of anxiety, depression, hallucinations, family functioning, the
implementation of psychiatric social work intervention, and the assessment of the effectiveness of the
intervention.For long term goal, Mr. Raj was urged to adopt a balanced perspective in order to lower his level
of worry by providing reassuring justifications and offering alternative ideas in response to those voices in
his head.He was instructed to keep a thought journal in which he would document any voices or thoughts he
encountered. He was instructed to record the time or occurrence when he heard voices, his belief or thought
at the moment, and the ensuing effects on how he felt.The goal of the session was to help the client recognize
early warning indicators of psychotic disorders and to create a self-management strategy that would kick in
when the client started exhibiting early warning signs and symptoms. The focus of the session was
identifying early warning signs and symptoms. The client was given the task of recording these signs and
symptoms and asking others to report any problems they observed.

4. Strategy

Tactical plan or approach:

The main approach utilized was Cognitive Behavioural Therapy (CBT), with an emphasis on providing
information about psychological processes, involving family members in the treatment, and modifying
cognitive patterns. For schizophrenia patients to recover quickly, effective psychosocial treatment is
required, such as cognitive-behavioural therapy, or CBT. Social work practice can benefit greatly from
CBT's relevance to schizophrenia. The current study's goal was to use a cognitive behavioral case work study
strategy to control auditory hallucinations.One of the most widely utilized and effective psychological
treatments for psychotic disorders is cognitive behavior therapy (CBT) (Rector et al., 2010). Applying
behavioral and cognitive-behavioral techniques to individuals with psychotic disorders has been the main
approach in the development of psychological therapy for voices (Jones et al., 2004). Through questioning
the apparent evidence that supports abnormal beliefs, encouraging self-monitoring of thoughts, teaching

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effective coping strategies for dealing with distressing symptoms, and highlighting the connection between
perceptions, beliefs, and emotional or behavioral reactions, cognitive behavioral therapy (CBT) aims to
modify an individual's non-adaptive thoughts and beliefs within the framework of a collaborative working
alliance (Morrison & Barratt, 2009; Berry & Hayward, 2011).

Mr Raj’s psychiatric symptoms and auditory hallucinations issues were treated using Cognitive behavioral
therapy.CBT sessions help Mr Raj to better understand how his thoughts and beliefs about voices affect his
emotions, mood, and coping mechanisms. Using the ABC paradigm as a guide, the session concentrated on
how thoughts affect emotions (A-Activating event, B-Belief, C-Consequences). Mr. Raj claimed during the
CBT session that he constantly heard voices, but he was unable to recall all they said. Hearing the voices also
caused him to feel agitated and nervous. Mr Raj determined that hearing voices when he was by himself was
the trigger event. Mr Raj was instructed to focus on his experiences in order to help him comprehend the
instinctive feelings and ideas that went along with it. He was also given an explanation of how the voices he
is hearing are impacting his emotions and ideas, as well as how he is becoming detached from reality.Mr. Raj
was asked to explain the connection between belief and outcomes.Mr Raj was urged to think rationally in
order to lower their degree of anxiety by providing constructive justifications and thinking about other ideas
in place of the voices. Mr Raj was made aware of some of the person's emotions, both happy and bad.
Three sessions comprised the conversation. He was instructed to keep a thought journal in which he would
document any voices or thoughts he encountered. He was instructed to record the time or occurrence when
he heard voices, his belief or thought at the moment, and the ensuing feelings he experienced.

Next, Mr Raj’s poor insight and coping issues were treated by behavioral skill training.Mr. Raj was asked
to explain the connection between belief and outcomes. The client was urged to think rationally in order to
lower their degree of anxiety by providing constructive justifications and thinking about other ideas in
place of the voices. The client was made aware of some of the person's emotions, both happy and bad. Three
sessions comprised the conversation. He was instructed to keep a thought journal in which he would
document any voices or thoughts he encountered. He was instructed to record the time or occurrence when
he heard voices, his belief or thought at the moment, and the ensuing feelings he experienced.Other soothing
techniques that were explored with Mr Raj were destruction, attention restriction, self-instruction, increasing
social engagement, and increasing sensory stimulation. Additionally,Mr Raj was directed to the
rehabilitation facility so that he may occupy himself with constructive tasks. Mr Raj benefited from the
diversion, relaxation, and soothing tactics, and he was able to comprehend the voices he had heard when
he was not involved in activities. When he got occupied, however, he stopped hearing voices. Mr Raj may
acknowledge that the voices he was hearing were a sign of mental illness and that he shouldn't focus on
them. Three sessions comprised the conversation.

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Furthermore, the problems of Mr Raj’s family members who had no prior knowledge of schizophrenia
disorder were counseled to acquire appropriate coping mechanisms and problem-solving abilities in order
to lessen the family's mental and physical load by finding solutions. Family psychoeducation is a clinically
grounded approach that teaches families to collaborate with mental health professionals as part of a family
member's comprehensive therapeutic treatment plan. It has been demonstrated that family psychoeducation
improves the prognosis of schizophrenia patients.

5. End the Session

A total of seventeen sessions were carried out, concluding with a discharge counseling that focused on the
characteristics of mental illness, adherence to medicine, involvement in constructive activities, and follow-up
arrangements.Mr Raj has received pre-discharge counseling to ensure that they continue their medication
regimen and treatment after being released from the hospital. The areas that were prioritized were What kind
of mental disease it is. The significance of taking prescription drugs, pharmaceutical side effects and the
significance of participating in productive activities. Following the discharge, there was further follow-up,
which involved phone calls.It was discovered that Mr. Raj was doing as he had been told. Right now, he's
holding up fine.

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4.0 Conclusion

The case study highlights the importance of implementing a thorough and personalized treatment strategy
such as was done for Mr. Raj, who was diagnosed with schizophrenia. The study shows promising results in
regards to treating the cognitive distortions and symptoms of schizophrenia by using cognitive behavioral
therapy (CBT).

Cognitive behavioral therapy (CBT) played a crucial role in cognitive restructuring, by questioning irrational
or distorted thoughts. Mr Raj, who initially experienced delusional thinking, showed a significant decrease in
these cognitive distortions. CBT appears to have played a role in transforming unhelpful thought patterns,
giving him a more accurate understanding of the world.

Schizophrenia has a range of symptoms, such as hallucinations, delusions, social isolation, and cognitive
deficits. Cognitive Behavioral Therapy (CBT) interventions were specifically aimed at addressing these
symptoms, providing strategies for the efficient management of them. The noticeable enhancement in
symptomatology highlights the significance of cognitive behavioral therapy (CBT) in reducing the adverse
effects of symptoms on the individual’s daily functioning.

Cognitive behavioral therapy gave Mr. Raj improved coping skills and mechanisms to manage stressors
which indicates the effectiveness of the treatment. The treatment offers better help in empowering
individuals to better manage stressors and demands of daily life.

When one explores the effectiveness of Cognitive Behavioral Therapy (CBT) in treating schizophrenia, one
could draw inspiration from the existentialist philosophers and the emphasis of personal responsibility.
Existentialist thinkers such as Jean-Paul Sartre, emphasize individual freedom and the idea that humans are
condemned to be free, meaning that we are responsible for our own actions. Accepting therapy is a profound
acceptance of personal responsibility in improving one’s own mental health, that individuals can shape their
own lives. Mr Raj’s journey is not merely managing symptoms but can be seen as a path towards self
actualization- the realization of one’s full potential. Amid the ruins of sanity, where the architecture of the
psyche crumbles, Cognitive Behavioral Therapy manifests as the defiant architect, constructing bridges of
reason over the abyss of irrationality.

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5.0 Reflection

The case study of Mr Raj has made me reflect on my own inner thoughts as my sometimes I feel like
my past self is the one who is demanding me to make a certain decision at the time, I figured out it is
my wounded inner child.I have diagnosed with Borderline Personality Disorder and I feel like I can
relate to Mr Raj as we have poor coping skills in understanding the cognitive pattern.I figure out I was
self sabotaging my life by making certain decision and ruining my relationship with loved ones , this is
because me as the inner adult was sitting in the driver’s seat not the one who was driving as that was
taken by my wounded inner child.By going through Cognitive behavioral therapy session like Mr Raj’s
did I will be able to to discover my negative thoughts pattern, by becoming aware to it my inner adult
will become conscious to it and then I will be able to take positive action in dealing with it.Therefore by
this my wounded inner child would also be able to heal and feel safe as I am acknowledging her by
becoming more aware of negative thoughts pattern that’s playing in my head and I am taking the
responsibilities as the inner adult to being able to provide emotional safety for my inner child.

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