Psychologist's First Session

**PRESENTING PROBLEM(S)** - Reports feeling overwhelmed and experiencing frequent anger outbursts. - Difficulty controlling emotional responses, feeling disproportionately upset by small things. - Reports vivid dreams related to past traumatic experiences. **HISTORY OF PRESENTING PROBLEM(S)** - Symptoms began approximately six months ago, following a stressful work situation. - Currently taking Sertraline 50mg daily, prescribed by GP. - Symptoms fluctuate, often worse during periods of high stress. **CURRENT FUNCTIONING** - Sleep: Reports difficulty falling asleep and frequent night-time awakenings. - Employment/Education: Employed full-time as a teacher. - Family: Married with two children; reports a supportive relationship with spouse but some conflict with extended family. - Social: Limited social activities due to work and family commitments. **PSYCHIATRIC HISTORY** - Psychiatric History: Previously attended counselling for anxiety, but treatment was discontinued two years ago. **DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY** **Family:** - Grew up in a stable household. - Reports a history of anxiety and depression in the family. **SUBSTANCE USE** - Reports occasional alcohol use, social drinking only. **SELF-HARM** - No history of self-harm. **RELEVANT CULTURAL/RELIGIOUS/SPIRITUAL ISSUES** - Relevant Cultural/Religious/Spiritual Issues: Attends church regularly and finds comfort in faith. **5P FORMULATION** - Presenting Problem: Experiencing symptoms of anxiety, anger outbursts, and sleep disturbances. - Predisposing Factors: Family history of anxiety and past traumatic experiences. - Precipitating Factors: Recent work-related stress and family conflict. - Perpetuating Factors: Difficulty expressing emotions and limited social support. - Protecting Factors: Supportive relationship with spouse and involvement in religious community. **CASE FORMULATION** The client presents with symptoms of anxiety, anger outbursts, and sleep disturbances, which began approximately six months ago. Predisposing factors include a family history of anxiety and past traumatic experiences. Precipitating factors include recent work-related stress and family conflict. Perpetuating factors include difficulty expressing emotions and limited social support. Protecting factors include a supportive relationship with their spouse and involvement in their religious community. **INTERVENTION** - Discussed the use of relaxation techniques and mindfulness practices. - Introduced cognitive restructuring techniques to challenge negative thoughts. - Explored the client's coping mechanisms and support systems. **GOALS** - Reduce the frequency and intensity of anger outbursts. - Improve sleep quality. - Develop effective coping strategies for managing stress and anxiety. **NEXT STEPS** - Recommend the client to practice relaxation techniques daily. - Assign homework to identify and challenge negative thoughts. - Schedule the next appointment for 15 November 2024. **NEXT APPOINTMENT** - Date: 15 November 2024 - Time: 10:00 AM - Duration: 50 minutes