Psychology Session Notes

Out of Session Task Review

• Client practised daily diaphragmatic breathing and progressive muscle relaxation (PMR) prior to sleep.

• Client maintained a CBT thought record focussing on workplace performance anxiety.

• Client reported completing the breathing exercises 5 out of 7 nights, noting a moderate reduction in sleep-onset latency (down to 30 mins from 60+ mins).

• Thought records were completed twice; Client found identifying cognitive distortions helpful in de-escalating acute panic symptoms.

• Client struggled to complete thought records in real-time during workday due to back-to-back meetings and fear of colleagues noticing.

• Reported fatigue in the evenings acted as a barrier to consistent journalling.

Current Presentation

• Client presents with ongoing generalised anxiety and occupational burnout.

• New concern raised regarding an upcoming quarterly performance review scheduled for next week, triggering somatic symptoms (GI upset, muscle tension).

• Slight improvement in sleep maintenance since last session.

• Decreased frequency of acute panic episodes (none this fortnight, down from 2 per week), though baseline anticipatory anxiety remains elevated.

Session Content

• Anticipatory anxiety surrounding upcoming meeting with line manager.

• Guilt associated with taking sick leave last month.

• Ongoing difficulty setting boundaries with after-hours work emails.

• Explored core beliefs relating to perfectionism and fear of failure ("If I make a mistake, I will be fired").

• Discussed the physiological link between chronic workplace stress and current somatic complaints.

• Goal 1: Reduce frequency and intensity of workplace-related panic and anxiety symptoms.

• Goal 2: Establish and maintain healthy work-life boundaries, specifically ceasing work communications after 18:00.

• Goal 1: Moderate progress; Client is successfully utilising somatic grounding techniques to prevent panic escalation.

• Goal 2: Minimal progress; Client continues to check work phone in bed due to fear of missing urgent tasks.

• Principal topic: Cognitive restructuring of catastrophic predictions regarding the upcoming performance review.

• Client realised that past performance reviews have consistently been positive and that current fears are driven by cognitive distortions (catastrophising, mind reading) rather than objective feedback.

• Client responded receptively to Socratic questioning, showing visible reduction in physical tension by the end of the exercise.

Intervention

• Cognitive Behavioural Therapy (CBT) – cognitive restructuring and Socratic questioning.

• Acceptance and Commitment Therapy (ACT) – values clarification regarding work versus personal health.

• Behavioural experiment design.

• Guided Client through a decatastrophising worksheet for the upcoming review; Client engaged collaboratively and generated realistic alternative outcomes.

• Conducted a brief in-session mindfulness grounding exercise; Client participated fully and reported an immediate drop in subjective units of distress (SUDS) from 7/10 to 4/10.

Setbacks/Barriers/Progress with Treatment

• Progress noted in emotional awareness and somatic symptom management.

• Primary barrier remains entrenched perfectionistic schemas and an unsupportive workplace culture that normalises overtime.

• Client expressed high satisfaction with the practical nature of CBT strategies, noting they feel "equipped with actual tools" rather than just venting.

Risk Assessment and Management

Suicidal Ideation

Client denies any current or historical suicidal ideation, intent, or plans.

Homicidal Ideation

Nil homicidal ideation reported or evidenced.

Self-harm

Nil history or current urges of deliberate self-harm.

Violence & Aggression

Nil history of violence or aggression; Client presents as placid and cooperative.

Management Plan

• Risk currently assessed as low.
• Continue routine monitoring of mood and occupational stressors.
• Client provided with standard crisis contact numbers (Lifeline 13 11 14) on intake documentation as a routine precaution.

Mental Status Examination

Appearance

Well-groomed, dressed appropriately in smart-casual attire, appears stated age.

Behaviour

Cooperative and engaged; mild psychomotor agitation noted initially (fidgeting with rings, tense posture) which settled midway through session. Good eye contact.

Speech

Normal rate, rhythm, and volume; coherent and articulate.

Mood

Described by Client as "stressed and on edge."

Affect

Anxious and slightly restricted initially, brightening appropriately during moments of humour; congruent with stated mood.

Thoughts

Logical and goal-directed stream of thought. Content preoccupied with occupational performance and future-oriented worry. Cognitive distortions of catastrophising and all-or-nothing thinking present. Nil delusions or formal thought disorder.

Perceptions

Nil auditory, visual, or other perceptual disturbances reported or observed.

Cognition

Alert and oriented to time, place, and person. Attention, concentration, and immediate/recent memory intact.

Insight

Good; Client recognises the disproportionate nature of their anxiety and its link to perfectionism.

Judgement

Intact; making reasonable decisions regarding healthcare, though occupational boundary-setting remains impaired by anxiety.

Out of Session Tasks

• Behavioural experiment: Leave work phone in the kitchen on silent from 19:00 to 07:00 for 3 consecutive weeknights to test the belief that "something terrible will happen" if unreachable.
• Complete one pre-meeting CBT thought record prior to the performance review to challenge anticipatory catastrophic thoughts.

Plan for Next Session

Next Session

24/10/2023 at 14:00 AEST.

• Debrief outcome of the quarterly performance review and the phone-boundary behavioural experiment.
• Introduce assertive communication strategies (DEAR MAN) to assist Client in negotiating workload with management.