Counselling Intake

PRESENTING PROBLEM(S) * The client reports persistent feelings of anxiety and overwhelming stress related to recent job loss and ongoing marital conflict. They express a sense of worthlessness and difficulty concentrating, leading to social withdrawal. * Client feels a significant loss of control over their life and is seeking strategies to manage their emotional distress and improve their relationships. HISTORY OF PRESENTING PROBLEM(S) * Onset of symptoms approximately 6 months ago, coinciding with initial discussions of company redundancies at work. * Anxiety initially manifested as mild worry, progressing to daily panic attacks and constant rumination following job termination 2 months ago. * Marital conflict, although present for several years, has significantly escalated in the past 3 months, with increased arguments and emotional distance from spouse. * Severity of symptoms fluctuates, but generally high, impacting daily functioning and leading to frequent crying spells. CURRENT FUNCTIONING Home Environment: * The client lives with their spouse in a rented flat. The home environment is currently tense due to marital issues. They report feeling emotionally isolated at home. Sleep: * Difficulty falling asleep and staying asleep, often waking multiple times during the night. * Reports waking feeling unrefreshed, averaging 4-5 hours of disturbed sleep per night. * The client states that racing thoughts about their job and marriage prevent them from relaxing. Education: * The client holds a Bachelor's degree in Business Administration. * No current educational pursuits. Employment: * Recently made redundant from a marketing management position, which they held for 10 years. * Currently unemployed and actively searching for new opportunities, but reports feeling demotivated and overwhelmed by the job search process. Family: * Spouse, Alex (45 years old): Relationship is strained, characterised by frequent arguments and a lack of emotional intimacy. * No children. * The client reports limited contact with their parents, who live in a different city, and a distant relationship with their sibling. Gender and Sexuality: * The client identifies as female and heterosexual. * Reports decreased sexual activity and intimacy due to current emotional distress. * Uses combined oral contraceptive pill. Culture/Religion/Spirituality: * The client identifies as agnostic but grew up in a Christian household. No current religious or spiritual practices. Social: * Reduced social interactions significantly since the onset of symptoms. * Has a small circle of friends, but has been cancelling plans frequently due to lack of energy and interest. * Feels supported by one close friend, but struggles to open up about the full extent of their difficulties. Exercise/Physical Activity: * Previously engaged in regular gym workouts (3 times a week) but has ceased this entirely in the past 3 months. * Reports feeling too fatigued and unmotivated to exercise. Eating Regime/Appetite: * Reports irregular eating patterns, often skipping meals or eating convenience food. * Experiences a fluctuating appetite, sometimes overeating and other times having no desire to eat. * No history or current signs of disordered eating or eating disorder. Energy Levels: * Consistently low energy levels throughout the day, particularly in the mornings. * Reports feeling drained even after minimal activity, which impacts their ability to engage in daily tasks. Recreational/Interests/Activities: * Previously enjoyed reading, painting, and gardening, but has lost interest in these hobbies. * Spends most of their free time at home, often watching television or scrolling on social media. Substance Use: * Reports drinking alcohol (wine) 3-4 times a week, typically 2-3 glasses per occasion, as a way to cope with stress. * Denies tobacco or illicit drug use. Legal Issues: * No current legal issues. MEDICATIONS Current Medications: None Past Medications: None PSYCHIATRIC HISTORY * No prior psychiatric hospitalisations. * Saw a counsellor briefly for 3 sessions five years ago following a bereavement, which they found moderately helpful. Other interventions: None Family: * Maternal aunt diagnosed with generalised anxiety disorder, managed with medication. MEDICAL HISTORY Personal Medical History: * Diagnosed with mild irritable bowel syndrome (IBS) managed with diet. * No other significant medical conditions. Family Medical History: * Father: Hypertension, well-controlled with medication. * Mother: Type 2 Diabetes. DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY Family: * The client is the eldest of two children. Parents, Sarah (70, retired teacher) and David (72, retired engineer), had a generally stable relationship but often avoided conflict. Sibling, Mark (42, architect), with whom the client has a cordial but not close relationship. Developmental History: * Achieved developmental milestones within normal ranges. * No reported early childhood issues or trauma. Gender and Sexuality: * Early relationships were stable but often involved the client prioritising partners' needs over their own. * No history of sexual health issues. Relationship History: * Prior to marriage, had two significant long-term relationships, both ending due to a lack of compatibility and the client's tendency to people-please. * Reports a pattern of seeking approval from partners. Educational History: * Consistently achieved good grades throughout primary and secondary school. * Attended university and completed a Bachelor's degree, maintaining strong academic performance. * Described as a diligent and conscientious student. Employment History: * Held various marketing roles, progressing steadily in their career until the recent redundancy. * Generally positive employment history, but recalls experiencing high levels of work-related stress in previous roles, which they often internalised. Legal History: * No legal history. Substance Use: * Experimented with cannabis a few times in university but ceased use shortly thereafter. * No history of problematic substance use prior to current increase in alcohol consumption. RISK ASSESSMENT Lowered Mood/Anxiety/Depression: * Client reports significant lowered mood, feelings of sadness, and hopelessness. * Experiences anxiety daily, including panic attacks. * Denies current self-harm. Anger: * Reports increased irritability and occasional outbursts of anger towards their spouse, which is uncharacteristic. * Expresses frustration with themselves and their situation. Safety: * Expresses concerns about their emotional well-being and ability to cope with current stressors. * No immediate threats to personal safety. Suicidal Ideation: * Denies current suicidal thoughts, intent, or plans. * Denies history of suicide attempts. * Expresses a desire to live and improve their situation. Homicidal Ideation: * Denies homicidal ideation. Self-harm (NSSH): * Denies history of self-harm. Violence & Aggression: * No history of physical violence or aggression towards others. Recent verbal aggression towards spouse is an anomaly for the client. Risk-taking/Impulsivity: * No current risk-taking behaviours or impulsivity reported. DIAGNOSIS * Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) CLINICAL FORMULATION Presenting Problem: * The client presents with symptoms of anxiety, low mood, and marital discord following recent job loss. * Significant impact on daily functioning, sleep, social engagement, and personal interests. Predisposing Factors: * History of internalising stress and people-pleasing tendencies in relationships. * Family history of anxiety. * Tendency to avoid conflict. Precipitating Factors: * Job loss 2 months ago. * Escalation of pre-existing marital conflict in the last 3 months. Perpetuating Factors: * Social withdrawal and isolation. * Ineffective coping mechanisms, including increased alcohol consumption. * Negative self-talk and rumination. * Avoidance of marital communication. Protective Factors: * Has one supportive friend. * Good educational and employment history indicates resilience and capability. * Insight into their current struggles and motivation to seek help. Case Formulation: Client presents with persistent anxiety, low mood, and marital discord, which appears to be precipitated by recent job loss and escalating marital conflict. Factors that predisposed the client to the problem include a history of internalising stress, people-pleasing tendencies, and a family history of anxiety. The current problem is maintained by social withdrawal, ineffective coping mechanisms such as increased alcohol consumption, negative self-talk, and avoidance of marital communication. However, the protective and positive factors include a supportive friend, a history of resilience and capability, and insight into their current struggles with a motivation to seek help.