Psychotherapy Process Note

Created by

Rebecca Thompson

Specialty

Clinical Psychologist

Last edited

10/20/2026

Uses

0 times

Tags

Clinical Psychologist

About this template

A concise structure for documenting psychotherapy sessions, including the presenting issue, interventions used, the client’s responses, the therapeutic process, and progress toward goals with future planning.

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Brief description of Presenting Issue: 32yo F, Sarah Jenkins (DOB: 12/05/1992, Medicare: 2849 10293 1), attended at 14:00 AEST on 18/10/2024 for session 4/10 under Better Access MHCP. Presenting w/ GAD and occupational burnout. Reports escalating work-related anticipatory anxiety, initial insomnia, and somatic sx (tension HA, GI upset) over the past 2/52 following a department restructure. Continues on escitalopram (Lexapro®) 10 mg PO OD managed by GP. Nil SI/SH or perceptual disturbances.

Therapeutic Interventions: Applied CBT and ACT frameworks. Conducted Socratic questioning to challenge catastrophic predictions regarding employment stability. Introduced cognitive defusion techniques ("I am having the thought that...") to create distance from perfectionistic self-talk. Completed in-vivo PMR to address physiological hyperarousal and reviewed sleep hygiene protocols.

Client’s Response: Engaged and cooperative, though initially restless (fidgeting, rapid speech). Demonstrated good insight during cognitive restructuring, successfully identifying "fortune-telling" and "all-or-nothing" cognitive distortions. Visibly relaxed post-PMR with reduced respiratory rate and softened affect. Expressed relief when separating self-worth from work productivity via defusion exercises.

Therapeutic Process: Mild resistance noted when shifting focus from external workplace stressors to internal perfectionism; client intellectualised her distress to avoid sitting with vulnerability. Transference observed as a strong desire to be a "good client," seeking validation for her completed thought logs. Countertransference included a pull to offer premature reassurance and problem-solve her workload, which was bracketed to encourage client autonomy and emotional tolerance.

Progress/Goals and Plan: Making steady progress toward Goal 1 (reducing perfectionistic standards and work-related rumination). Newly established Goal 2: Implement firm digital boundaries (no work emails after 18:00). Plan:

Client to complete daily thought record focusing on alternative balanced thoughts.
Practice 10-min PMR audio prior to bed.
R/V in 2/52 (01/11/2024 at 14:00 AEST) to commence graded exposure to delegating tasks at work.

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