Clinical Intake Assessment

Counselling Psychologist Clinical Intake Assessment Understanding the Presenting Issue(s) Reason for calling / engaging with the service: The Client sought therapy due to a progressive increase in anxiety symptoms over the past six months, culminating in recent panic attacks. The onset was gradual, initially triggered by workplace stress, but has since expanded to impact social interactions and daily functioning. The client reported feeling overwhelmed and unable to manage the anxiety on their own, noting a desire to regain control and improve overall well-being. Presenting Issue(s) / Symptoms: * Generalised anxiety and worry * Panic attacks (weekly for the past month) * Difficulty sleeping (insomnia, frequent awakenings) * Avoidance of social situations * Muscle tension and headaches Relevant History / Prior Trauma(s): The client reported a history of parental separation during childhood (age 8), which they describe as having created a sense of insecurity and abandonment. They also mentioned a significant interpersonal conflict with a former colleague two years ago, leading to their departure from a previous job, which instilled a deep-seated fear of conflict and rejection. These experiences have contributed to a pattern of self-doubt and difficulty forming secure attachments. The severity of the childhood parental separation is reported as moderate, leading to ongoing attachment anxieties. The impact of the workplace conflict was high, significantly affecting the client's self-esteem and career trajectory, leading to persistent social anxiety. Primary Presenting Issue: Generalised Anxiety Disorder with Panic Attacks Coping Strategies and Protective Factors Coping Mechanisms and Supportive Factors: * Regular exercise (3-4 times per week) * Journaling * Support from a close friend (confides in friend weekly) * Adequate nutrition (three meals daily) * Moderate sleep (6 hours, often fragmented) Any changes to or resistance towards coping strategies and support systems including whether the client has someone to confide in: The client noted that their usual coping strategies, particularly exercise, have become less effective in managing the escalating anxiety. They expressed resistance to discussing their deepest fears with their supportive friend, fearing they would be a burden. This has led to feelings of isolation despite having someone to confide in. Substance Use / Abuse: * Alcohol: Occasional (1-2 units, 2-3 times per month), no current impact on functioning, last use 2 days ago. No prior treatment history. * Cannabis: None. * Other illicit substances: None. Workplace Impact / Safety: The client is employed as a Marketing Manager. Their role involves frequent presentations and client interactions, which are significantly impacted by their anxiety, particularly the fear of panic attacks in public. There are no immediate safety-critical aspects to the role, but their performance is declining, leading to concerns about job security. Past Medical History Mental Health Diagnosis / Medication: * Diagnosed with Generalised Anxiety Disorder (GAD) 5 years ago by a GP. No formal psychiatric diagnosis. * Medication: Escitalopram 10mg daily for the past 3 months (compliance is good, dosage has not been adjusted, no significant improvement noted). Previous Experience of Therapy: The client had 6 sessions of Cognitive Behavioural Therapy (CBT) approximately 4 years ago for milder anxiety. They reported learning some useful cognitive restructuring techniques, but felt the therapy ended prematurely and they did not fully consolidate the skills. Outcomes were initially positive but not sustained. Trauma Factors Symptoms of Trauma: * Intrusive memories of past conflicts (severity: moderate, frequency: 2-3 times per week, impact: distracts from daily tasks) * Avoidance of reminders of past social rejection (severity: high, frequency: daily, impact: limits social engagement) * Hypervigilance in social settings (severity: moderate, frequency: constant in social situations, impact: causes exhaustion) Risk Assessment Assessment of Risk: * No past attempts to end life. * No current intent or plan for self-harm. * Impulse control is generally good. * Psychological disturbance is present due to anxiety symptoms. * Support network includes a close friend and family, though client is reluctant to fully confide. * No family history of mental health hospitalisation. * Age: 34, Gender: Female. Imminent Risk Identified: No imminent risk of self-harm or harm to others identified. Safeguarding Required / Imminent Safeguarding Risk Identified: No safeguarding concerns identified. Risk Management / Safety Plan / Action Plan: No specific safety plan required at this stage beyond general anxiety management strategies. No physical harm identified. Outcome / Clinical Recommendations Outcome of Session: The session revealed that the client's current anxiety is significantly linked to unresolved issues from childhood abandonment and later interpersonal trauma. There is a clear pattern of avoidance and difficulty with emotional expression contributing to the escalating symptoms. The client expressed a strong desire for change and openness to engaging in deeper therapeutic work. The therapist observed the client to be articulate and introspective, yet visibly distressed when discussing past relational difficulties. There was a clear indication of a need for a therapeutic approach that addresses both cognitive and emotional processing of past experiences. Recommendations: * Psychoeducation on anxiety and trauma responses to normalise experiences. * Introduction to emotional regulation techniques. * Exploration of attachment patterns and their impact on current relationships. * Development of assertive communication skills. Whether further assessment or specialist referral has been suggested: No further assessment or specialist referral is immediately suggested, as the current presentation falls within the scope of counselling psychology. Clinical Rationale for Recommendation: The recommendations are based on the client's presenting anxiety and panic, which appear to be rooted in historical trauma and attachment insecurities. A holistic approach incorporating psychoeducation, emotional regulation, and a focus on relational dynamics is likely to be most effective in addressing the underlying causes of their distress and building long-term resilience. Counselling Referral SU Goals: * Understand the root causes of anxiety. * Develop effective coping mechanisms for panic attacks. * Improve sleep quality. * Re-engage in social activities with confidence. Client's specific goals for therapy and desired outcomes: * Client will identify 3 triggers for anxiety within the next 4 weeks. * Client will practice 2 new relaxation techniques daily for the next 6 weeks, aiming to reduce panic attack severity by 50%. * Client will attend 3 social gatherings in the next 2 months, aiming to reduce social avoidance. * Client will express feelings more openly with their friend at least once a week for the next 8 weeks. Number of Sessions Recommended: 12-16 sessions. Treatment Plan / Focus: Therapy sessions will initially focus on stabilising the client's current anxiety symptoms through psychoeducation and the introduction of distress tolerance and emotional regulation skills. Subsequent sessions will delve into exploring the historical context of their anxiety, including past traumas and attachment patterns, using an integrative approach incorporating elements of psychodynamic therapy and Cognitive Behavioural Therapy (CBT). Collaborative goal setting will be continuous, adapting as the client progresses. Specific plan for how each session will be used in service of the stated therapy goals: 1. Initial assessment, rapport building, psychoeducation on anxiety cycle. 2. Introduction to diaphragmatic breathing and progressive muscle relaxation. 3. Cognitive restructuring techniques for anxiety-provoking thoughts. 4. Exploration of childhood experiences and their impact on current self-perception. 5. Identification of attachment styles and their manifestation in adult relationships. 6. Processing of the workplace conflict and associated feelings of rejection. 7. Developing assertive communication skills for current interpersonal challenges. 8. Exposure hierarchy for social situations, starting with low-anxiety scenarios. 9. Consolidating coping strategies and identifying relapse prevention techniques. 10. Review of progress and adjustment of therapeutic goals. 11. Further integration of self-compassion practices and self-soothing techniques. 12. Planning for termination and maintaining therapeutic gains.