ACT Session Progress Note

• Mental State Examination: Neatly groomed, casual attire. Cooperative and engaged, though initially restless with frequent hand-wringing. Speech normal in rate, rhythm, and volume. Affect anxious and restricted, congruent with reported workplace stress. Thought form linear and logical; content notable for anticipatory anxiety and fear of failure, nil suicidal or homicidal ideation. Nil perceptual disturbances, hallucinations, or depersonalisation reported. Alert and oriented x3, attention and memory intact. Insight and judgement fair.

• Client Update: Delivered a major project pitch on 14/05/2026. Experienced panic symptoms prior (tachycardia, diaphoresis) and called in sick the following day to avoid supervisor feedback. Adherent to escitalopram (Lexapro®) 10 mg PO OD.

• Client history: 32yo F with GAD, referred under GP Mental Health Treatment Plan (Session 4/10). History of perfectionism and workplace burnout over the past 18 months.

• Agenda: Client requested strategies to manage acute pre-meeting anxiety. Therapist objective: target experiential avoidance related to professional evaluation and introduce cognitive defusion techniques.

Hexaflex Observations

• Avoidance/Acceptance: High experiential avoidance demonstrated by taking sick leave to escape potential criticism and uncomfortable somatic sensations. Showed emerging willingness to sit with mild anxiety in-session when discussing the pitch.

• Fusion/Defusion: Strongly fused with the thought "If I make a mistake, I'm incompetent and will be fired." Behaviour is currently dictated by these catastrophic predictions rather than actual performance metrics.

• Self-as-content/Self-as-context: Over-identifies with the "anxious perfectionist" label (self-as-content). Struggles to access the observing self, viewing anxious thoughts as objective truths about her professional identity rather than transient mental events.

• Values/Remoteness from values: Values professional growth, authenticity, and collaboration, but current trajectory is remote from these due to avoidance-driven behaviours and emotional reactivity.

• Committed action/inaction or stuck: Stuck in inaction regarding career progression; actively procrastinating on reviewing post-pitch feedback emails due to fear of negative evaluation.

• Interventions: Explored workability of avoidance strategies (short-term relief vs. long-term career stagnation). Introduced "Passengers on the Bus" metaphor to illustrate moving toward values despite anxious thoughts. Practised "I'm having the thought that..." defusion exercise targeting impostor syndrome narratives.

• Outcomes: Client engaged well with the metaphor, identifying her "passengers" as perfectionism and self-doubt. Reported a slight reduction in emotional attachment to the "incompetent" thought following the defusion exercise, noting it felt "less heavy." Agreed to open and read the feedback email prior to the next session as a value-aligned committed action.

• Follow-up: 28/05/2026 at 14:00 (Australia/Sydney). Review homework (reading feedback email and daily 5-minute defusion practice).