Clinical Intake Assessment

Counselling Psychologist **Understanding the presenting issue(s)** **Reason for calling / engaging with the service:** The patient, Mrs. Eleanor Vance, aged 42, engaged with the service due to escalating anxiety and persistent low mood, which she reports began approximately six months ago following a significant promotion and increased responsibilities at work. The onset was gradual, initially manifesting as difficulty sleeping and increased worry, but has progressed to impact her daily functioning, particularly her ability to concentrate and engage in social activities. Precipitating factors include a demanding work environment and a recent argument with her sister, which left her feeling isolated. Triggers for seeking support now include panic attacks occurring weekly and a growing sense of hopelessness. **Presenting Issue(s) / Symptoms:** * Generalised anxiety: characterised by excessive worry, restlessness, and difficulty concentrating. * Low mood: persistent feelings of sadness, anhedonia (loss of pleasure), and fatigue. * Panic attacks: sudden episodes of intense fear accompanied by palpitations, shortness of breath, and dizziness, occurring weekly. * Insomnia: difficulty falling and staying asleep, leading to chronic tiredness. * Social withdrawal: reduced engagement in previously enjoyed social activities and increased isolation. **Relevant History / Prior Trauma(s):** Mrs. Vance reported a history of parental divorce during her adolescence (age 14), which she describes as a period of significant emotional upheaval and insecurity. She did not receive formal therapy at that time but attributes some of her current struggles with control and people-pleasing to this experience. There is no current or historic formal diagnosis. The issues have significantly impacted Mrs. Vance's professional performance, leading to missed deadlines and increased stress, as well as her personal life, where she feels disconnected from her family and friends. Her ability to enjoy hobbies has diminished, and she often feels overwhelmed by routine tasks. **Primary presenting issue:** Generalised anxiety and low mood. **Coping strategies and protective factors** **Coping mechanisms, supportive factors:** Mrs. Vance currently attempts to cope by exercising (jogging 2-3 times a week), watching television, and occasionally confiding in her husband. Her eating habits have become irregular, often skipping meals or overeating. Sleep is severely disrupted. Daily functioning is maintained but with significant effort. Her husband is a primary source of support, though she often feels she is burdening him. She has a small circle of friends but has been reluctant to confide in them recently. Mrs. Vance noted a recent decrease in the effectiveness of her usual coping strategies, particularly exercise, which no longer provides the same level of relief. She expressed resistance to discussing her struggles with friends, fearing judgment or appearing weak. While she confides in her husband, she feels a need to protect him from the full extent of her distress. **Substance Use/Abuse:** Mrs. Vance reports occasional alcohol use (2-3 units per week), primarily on weekends, which has not increased since the onset of her symptoms. There is no history of substance abuse or treatment. **Workplace impact/safety:** Workplace impact is significant due to decreased concentration and increased absenteeism. Mrs. Vance is a Senior Marketing Manager, a role with high pressure and requiring frequent public speaking. Her role is not safety-critical, but the impact on her performance is causing considerable stress and fear of professional repercussions. **Work Impact Score (if applicable)** 7/10 **Past medical history – Diagnosis, medication, experience of therapy** **Mental health diagnosis /Medication?** No formal mental health diagnoses. Mrs. Vance is not currently taking any prescribed medication for her mental health. **Previous experience of therapy?** Mrs. Vance had 6 sessions of Cognitive Behavioural Therapy (CBT) five years ago for mild work-related stress. She found it moderately helpful at the time, learning basic thought-challenging techniques. She remembers it being a positive experience, but the strategies did not fully equip her for the current level of distress. **Trauma factors** **Symptoms of trauma:** No explicit trauma-related symptoms such as intrusion, avoidance, hyperarousal, irritability, or paranoia were reported or observed. The earlier parental divorce, while emotionally impactful, does not present with current trauma symptomatology. **Risk Assessment** **Assessment of risk:** Mrs. Vance denies any current intent or plan to end her life. She reports good impulse control and a strong desire to overcome her current difficulties. Her support network, particularly her husband, acts as a protective factor. No history of physical illness or family history relevant to suicide risk was identified. Age (42) and gender (female) are noted but not considered specific risk factors in this context. **Imminent risk identified:** No imminent risk of self-harm or harm to others was identified. **Safeguarding required / Imminent safeguarding risk identified:** No safeguarding concerns were identified. **Risk Management / Safety Plan / Escape plan / Action plan:** A preliminary safety plan was discussed, focusing on maintaining communication with her husband about her feelings and engaging in previously enjoyed activities, even for short periods, when anxiety becomes overwhelming. She agreed to contact the service if her feelings of hopelessness intensify. **Pre-outcome measure** **CORE10 Score (please include the CORE 10 prior to submitting for review):** 18 **Outcome / Clinical recommendation(s)** **Outcome of session:** The session provided a comprehensive overview of Mrs. Vance's presenting issues, including the recent escalation of anxiety and low mood, their impact on her daily life, and relevant historical factors. Key themes included feelings of overwhelm, isolation, and a perceived loss of control. Mrs. Vance expressed a strong desire for change and demonstrated good insight into the connections between her work stress and emotional state. The therapist observed Mrs. Vance to be articulate and motivated, though visibly distressed. Her responses indicated a tendency towards self-criticism and a desire to meet high expectations, potentially contributing to her anxiety. **Recommendations:** Structured therapy sessions focusing on Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT) approaches are recommended. The initial focus will be on psychoeducation regarding anxiety and low mood, developing emotional regulation strategies, and exploring values-based living to enhance coping and resilience. Further assessment will be conducted in subsequent sessions to refine the treatment plan. **Clinical rationale for recommendation:** The combination of CBT and ACT is clinically indicated given Mrs. Vance's presenting symptoms of anxiety and low mood, and her reported struggles with perfectionism and emotional regulation. CBT will help address negative thought patterns and maladaptive behaviours, while ACT will foster psychological flexibility and committed action towards her values, supporting her in navigating workplace pressures and improving overall well-being. **Counselling referral (if applicable)** **SU Goals (Specific, Measurable, Achievable, Realistic, Timebound):** * **S**pecific: Reduce feelings of overwhelming anxiety and sadness, improving sleep quality. * **M**easurable: Report a decrease in weekly panic attacks from current 1-2 to 0-1 within 6 weeks; report 5 nights of undisturbed sleep per week within 8 weeks. * **A**chievable: Implement 3 new coping strategies (e.g., mindfulness exercises, structured relaxation) daily. * **R**ealistic: Re-engage in one previously enjoyed social activity per week. * **T**ime-bound: Achieve a noticeable reduction in overall distress by the end of 10 sessions. Goals were collaboratively set with Mrs. Vance, who expressed agreement and motivation to work towards them. The emphasis was placed on gradual, sustainable changes. **Number of sessions recommended:** 10-12 sessions. **Treatment Plan / Focus (how will the sessions be used):** Therapy sessions will be structured to collaboratively address Mrs. Vance's goals. Initial sessions will focus on psychoeducation about anxiety and depression, developing a shared understanding of her difficulties. We will then introduce practical coping strategies derived from CBT, such as cognitive restructuring and exposure techniques for anxiety-provoking situations. Subsequent sessions will incorporate ACT principles, including mindfulness, values clarification, and committed action, to help Mrs. Vance navigate workplace stress and improve her emotional well-being. We will explore boundary setting and self-compassion to address her people-pleasing tendencies. Specific modalities will include guided meditations, thought records, and behavioural experiments. Each session will build upon the previous, with a review of progress and assignment of home practice to integrate learned skills into daily life.