Process Notes

Process

• Ongoing work-related stress, return-to-work anxiety, and persistent early morning awakening.
• Completed 4/7 days of behavioural activation diary; attended one social event with friends without leaving early.
• Avoided confrontation with line manager regarding phased return; struggled with ruminative thoughts in the evenings.
• Adherent to sertraline (Zoloft®) 100 mg PO OD; mild GI upset has now resolved.
• Cognitive restructuring targeting catastrophising around workplace performance; sleep hygiene psychoeducation.
• Assigned Homework: Complete thought record for 3 anxious episodes; draft email to HR regarding phased return adjustments.

Current Functioning

• Mood: Subdued but less labile; rated 5/10 (up from 3/10 two weeks ago).
• Sleep: Initial insomnia improved; still experiencing EMW around 04:30, averaging 5.5 hours/night.
• Employment/Education: Currently signed off work (week 4 of sick leave from IT project manager role); planning phased return next month.
• Family: Supportive partner at home; some tension regarding household finances during sick leave.
• Social: Met two close friends for coffee on Saturday; otherwise relatively isolated during weekdays.
• Exercise/Physical Activity: Walking dog for 20 mins daily; has not yet resumed gym attendance.
• Eating Regime/Appetite: Appetite returning to baseline; eating two regular meals per day.
• Energy Levels: Low in the mornings, improving slightly by mid-afternoon.
• Recreational/Interests: Reading fiction for 15 mins before bed; still lacks motivation for playing guitar.

Presentation

• Appearance: Casually dressed, well-groomed, appropriate to weather.
• Behaviour: Cooperative, engaged, mild psychomotor retardation noted initially, good eye contact.
• Speech: Normal rate, rhythm, and volume; spontaneous.
• Mood: "A bit flat, anxious about work."
• Affect: Mildly restricted, congruent with stated mood, reactive at times.
• Perception: Nil hallucinations, illusions, or depersonalisation/derealisation.
• Thought Process: Linear, logical, and goal-directed.
• Thought Form: No formal thought disorder; ruminative themes around occupational competence.
• Orientation: Oriented to time, place, and person.
• Memory: Grossly intact for immediate, recent, and remote events.
• Concentration: Mildly impaired during complex cognitive restructuring tasks, otherwise adequate.
• Attention: Sustained throughout the 50-minute session.
• Judgement: Intact; making reasonable decisions regarding phased return to work.
• Insight: Good; recognises connection between perfectionistic traits and current burnout/depressive episode.

Risk Assessment

• Suicidal Ideation: Nil current active SI, intent, or plans. Passive fleeting thoughts of "wanting to disappear" two weeks ago have resolved. No history of attempts.
• Homicidal Ideation: Nil reported or evidenced.
• Self-Harm: No current urges; history of superficial cutting in adolescence (over 15 years ago).
• Violence & Aggression: Nil history or current risk.
• Addictive Behaviours: Non-smoker; alcohol intake reduced to 4 units/week; nil illicit substance use or gambling.
• Risk-Taking/Impulsivity: Nil reported; behaviour remains cautious.

Treatment Plan

• Goals for Treatment: Remission of depressive symptoms, restoration of sleep architecture, and successful graded return to full-time employment with healthy boundary setting.
• Outcome Measures: PHQ-9 (today: 13, baseline: 19) and GAD-7 (today: 11, baseline: 16) administered fortnightly.

Session Summary

The patient attended on time and engaged well in today's session, demonstrating steady improvement in mood and biological symptoms since titrating sertraline 100 mg PO OD. Risk remains low with complete resolution of previous passive suicidal ideation and strong protective factors in place. Cognitive restructuring was utilised to challenge catastrophic automatic thoughts regarding his upcoming return to work, alongside behavioural activation review. While he has made positive strides in social re-engagement, avoidance of communication with his employer remains a key barrier to his occupational goals. We agreed on graded exposure tasks involving contacting HR this week, and we will review his progress and repeat outcome measures in two weeks.

Supervision

• Mild countertransference of wanting to "rescue" the patient by offering direct advice on HR policies rather than facilitating his own problem-solving.
• Discuss strategies for addressing entrenched perfectionism if standard CBT thought records plateau over the next two sessions.