Client: Sarah Jones
Date: 1 November 2024
Worker: Dr. Emily Carter
**MSE:**
Appears her age, well-groomed, cooperative, normal speech, congruent mood, appropriate affect, linear thought process, no active suicidal ideation, intact cognition, good insight, low risk.
**Presenting Issue:**
- Reports feeling overwhelmed by work and family responsibilities.
- History of anxiety and occasional panic attacks.
- Seeking strategies to manage stress and improve coping mechanisms.
**Focus/Support:**
- Explored the client's current stressors and triggers.
- Discussed relaxation techniques and mindfulness practices.
- Provided psychoeducation on anxiety management.
**Next Step:**
- Schedule a follow-up session next week.
- Client to practice relaxation techniques daily.
- Client to consider joining a support group.
**PTMF:**
Power:
- Feeling of being controlled by external demands.
- Lack of control over work environment.
Threat:
- Financial pressures.
- Fear of failure.
Meaning:
- Believes she must always be productive.
- Sees herself as responsible for everyone's happiness.
Response:
- Avoidance of difficult situations.
- Increased irritability.
Strengths:
- Strong support network.
- Resilience in the face of adversity.
Story:
Sarah's narrative centres on a lifelong pattern of over-achievement and people-pleasing, leading to chronic stress and anxiety. She is beginning to recognise the impact of these patterns and is motivated to make changes.
**Outcome:**
Sarah engaged actively in the session, expressing a willingness to explore new coping strategies. She appeared relieved to have a space to discuss her challenges and left feeling hopeful about the future.