Psychotherapy Session Note

Psychotherapist Session Note The patient consented to a phone session. She presented with ongoing anxiety related to work stress and difficulties in setting boundaries with colleagues. Her presenting complaints include frequent panic attacks, insomnia, and persistent feelings of overwhelm that have been escalating over the past two months. She reported a past medical history significant for migraines managed with over-the-counter medication, with no previous surgeries. The patient is currently taking Fluoxetine 20mg daily for anxiety and occasional chamomile tea for sleep. Social history includes living with a partner, working full-time as a marketing manager, and infrequent social outings due to fatigue. The patient has no known allergies. During the session, the patient appeared somewhat dishevelled, but her mood was cooperative and engaged. She demonstrated coherent thought processes and articulate speech, though her rate of speech was slightly accelerated when discussing her stressors. The patient's affect was congruent with her expressed feelings of anxiety, showing moments of tearfulness and heightened tension. She is currently experiencing significant challenges with self-esteem and a fear of confrontation, which contributes to her boundary issues. The demonstrated strengths include a strong desire for self-improvement, good insight into her emotional patterns, and a commitment to therapy. Interventions: Cognitive restructuring techniques to challenge negative automatic thoughts, psychoeducation on assertiveness training, exploration of underlying fears related to boundary setting. Homework: Practice one assertive communication skill with a low-stakes interaction, journal about feelings and triggers related to work stress, engage in a 10-minute mindfulness exercise daily. Next Session: 1 November 2024