PIRP

PIRP **Clinician Specialty:** Cognitive Behavioral Therapist **Problem:** Ms. Davies presented to the session reporting persistent feelings of anxiety, particularly in social situations and when facing work-related deadlines. She described experiencing a racing heart, shallow breathing, and difficulty concentrating, which have been impacting her professional performance and personal relationships. The client reported an increase in avoidance behaviours, often declining social invitations and procrastinating on tasks due to overwhelming feelings of dread. This session was necessary to continue addressing these patterns, building upon previous coping strategies, and monitoring her progress in applying learned techniques. While some progress has been noted in identifying triggers, remaining impairments include occasional panic attacks and a tendency to catastrophise outcomes. The current diagnosis of Social Anxiety Disorder and Generalized Anxiety Disorder remains accurate and adequately describes her presenting challenges. The medical necessity of this session stems from the ongoing impact of these symptoms on her daily functioning and quality of life, requiring continued therapeutic intervention. **Intervention:** The clinician engaged Ms. Davies in a structured review of her thought records from the previous week, specifically focusing on identifying cognitive distortions related to a recent work presentation. Cognitive restructuring techniques were then reinforced, guiding Ms. Davies to challenge her negative automatic thoughts and replace them with more balanced and realistic appraisals. The clinician introduced and modeled a new coping skill: a progressive muscle relaxation exercise combined with diaphragmatic breathing, designed to be used proactively before anticipated stressful events. Strengths such as her commitment to practice and her insightful self-reflection were acknowledged and reinforced. A brief risk assessment was conducted, confirming no immediate risk of harm to self or others. The clinician advised Ms. Davies to continue practicing thought challenging daily and to incorporate the new relaxation technique twice a day, especially in the mornings, and prior to any upcoming social or work-related challenges. The importance of self-compassion during this process was also highlighted. **Response:** Ms. Davies demonstrated active engagement during the session, particularly in identifying her cognitive distortions. She reported feeling a slight reduction in her anxiety during the session when practicing the cognitive restructuring techniques. Her behavioural response to the introduction of progressive muscle relaxation was positive, stating that she felt a sense of calm after practicing the technique with the clinician. While she acknowledged the difficulty in consistently applying these skills outside of the session, she expressed a renewed commitment to practice. Progress towards her treatment plan goal of reducing social avoidance behaviours was observed, as she reported attending a small social gathering last weekend, albeit with some initial discomfort. However, there was a noted lack of significant change in her overall anxiety levels during high-stress work situations, indicating a need for continued focus on in-vivo exposure techniques. The client's self-reported anxiety scores on a GAD-7 assessment completed prior to the session showed a slight decrease from the previous week, moving from 18 to 16, indicating some measurable, albeit modest, progress. **Plan:** To achieve her treatment goals, the next steps include continuing to reinforce cognitive restructuring and introducing graded in-vivo exposure exercises for social situations. The clinical decision was made to begin with lower-stakes social interactions, such as ordering coffee or making a small purchase. Ms. Davies will continue to utilise the thought records and practice the progressive muscle relaxation technique. No specific referrals are needed at this time, but a follow-up appointment is scheduled for 1 November 2024, at 10:00 AM. Homework assignments for the client include documenting three instances of practicing the new relaxation technique and attempting one low-stakes social interaction, noting her thoughts and feelings before and after. The existing treatment goals remain appropriate, with an emphasis on further developing her distress tolerance skills and reducing avoidance behaviours. Treatment titration or discharge is not considered at this stage, as Ms. Davies continues to benefit from ongoing therapeutic support.