Psychotherapeutic Assessment and Management of Social Anxiety Disorder

This case details the psychotherapeutic assessment and management of a patient suffering from social anxiety disorder and psychological vulnerabilities.

Psychology

Table of Contents
Introduction......................................................................................................................................4
Patient Demographics......................................................................................................................4
Referral............................................................................................................................................4
History of Presenting Complaint.....................................................................................................4
Past psychiatric history....................................................................................................................6
Past medical history.........................................................................................................................6
Medications......................................................................................................................................6
Substance use history.......................................................................................................................7
Personal history...............................................................................................................................7
Forensic history...............................................................................................................................8
Occupational history........................................................................................................................8
Social history...................................................................................................................................9
Mental state examination.................................................................................................................9
Physical Examination....................................................................................................................10
Formulation....................................................................................................................................10
Diagnosis.......................................................................................................................................11
Management Plan..........................................................................................................................12
Medication.................................................................................................................................12
Psychotherapy............................................................................................................................12
Assessment of Suitability for Psychotherapy................................................................................14
Health-sickness dimension........................................................................................................14
Psychological dimension...........................................................................................................15
Therapy dimension....................................................................................................................15
Goals of psychotherapy.................................................................................................................15

Supervision and learning goals......................................................................................................16
Setting and frame...........................................................................................................................18
Progress: Summary of Psychotherapy Sessions............................................................................18
Session 1-5.................................................................................................................................18
Session 6-10...............................................................................................................................20
Session 11-15.............................................................................................................................21
Session 16-20.............................................................................................................................22
Session 21-25.............................................................................................................................24
Session 26-30.............................................................................................................................25
Session 31-35.............................................................................................................................26
Session 36-40.............................................................................................................................28
Discussion......................................................................................................................................29
Conclusion.....................................................................................................................................30
Reference List................................................................................................................................30

Introduction
This case details the psychotherapeutic assessment and management of a patient suffering from
social anxiety disorder and psychological vulnerabilities.
Patient Demographics
Anna was a 45 year old* mother of three. She has two daughters* and a son*. She was married
and lived with her husband and children. Anna worked as a full time freelance performer* and
really enjoyed her job. In her house, she was the primary financial provider as her husband took
care of all the household work. She had been suffering from social anxiety symptoms from 22
years. It was primarily due to difficult experiences in her early age and she also had a very
complicated relationship with her mother. It was reported that her mother had suffered from
hypochondriasis. Currently, Anna consumes alcohol more than the levels of safe drinking,
however, has been working to reduce the same. She was ex-smoker. She had never engaged in to
self harming or suicidal behaviors.
Referral
Initially, the general practitioner of Anna referred to an anxiety clinic for the GAD assessment.
The practitioner prescribed her with propranolol 10 mg to be used 30 minutes before any
performance. The general practitioner also prescribed Anna with 2mg of diazepam at her review.
According to the practitioner, no chronic medical conditions were found within Anna, however,
slight rosacea and an insertion of Mirena was found within her.
History of Presenting Complaint
It was described by Anna that she had a history of 22 years of warning and waxing symptoms
related to performance anxiety. This was followed by an embarrassing scenario which took place
during her live performance where she ran out of breath. Running towards the location, caused
Anna to struggle with words and fall short of breath. She was questioned by people if she was
fine which made her fear that people might have come to know about her anxiety issues. As
stated by Anna, severe amount of anticipatory anxiety was developed inside her before live
performances. This often made her scared to be judged negatively due to which signs of anxiety
and embarrassment had developed more inside her. The primary symptoms of anxiety faced by

Anna were shortness of breath, a shaky voice and trembling. Before I feared performance, the
anticipatory anxiety of Anna could build for several days. During such times, she claimed of
getting several unhelpful thoughts. It was also recognized by her that she used to compare herself
with her colleagues in a negative manner. The constant fears of Anna were the repetition of the
scenario, and people noticing her anxious stare and making fun of it. Any kind of rumination
after the event was denied by Anna to which she explained that if her performance went well, she
felt good about it and if vice-versa, she tried to forget it. Such fears are a part and parcel of the
mental health issue related to Social Anxiety Disorder.
It was recognized by her that often her anxiety was triggered by some specific performances then
the others. Anna also explained about experiencing panic symptoms which were situation bound
such as a feeling of dizzy, twitchy, bushing and racing heart. Any kind of paraesthesia or
diaphoresis was denied by her. Dissociative symptoms like depersonalization or derealisation
were also denied by her. No associated panic cognitions were found either. Anna explained that
the panic symptoms experienced by her only occurred at times when she was already highly
anxious and not out of the blue.
Situations where Anna was the centre of attention, like a doctor’s appointment or a party, she
reported of having social anxiety which was more generalized.
In the past years, she had been trying to manage herself and fight anxiety in her own ways. She
took precautionary measures such as keeping a water bottle nearby, making small talks, taking
propranolol and so on.
According to her, the symptoms became worse one and half year back. It took place after an
encounter of Anna with her mother. She explained that she did not like her mother and tried to
block all possible contacts with her. She described that since her last meeting with her mother,
the symptoms of anxiety had increased and become very intense and frequent. Although her
mood had been stable, a reduction in memory and concentration was reported by her.
No symptoms of dysthymia or depression were found in her. There were no instances of diurnal
mode variation. She described of having good energy levels, stable weight, healthy appetite, ok
sleep and normal libido. Any kind of perceptual disturbances delusional ideation and thoughts of

self harm or harming others were denied by her. A strong desire of engaging into views was
expressed by Anna.
Past psychiatric history
The first instance of seeking help for anxiety symptoms was made by Anna in 2001. During that
point of time, she experienced occasional panic related symptoms and mild anxiety. The general
practitioner of Anna referred her to a psychologist whom she visited thrice for sessions of CBT.
There she learned about breath controlling and other relation techniques. And I was able to
recognize the abnormal nature of the behavior of her mother and how it affected her
psychological development. According to her, she never had any previous psychiatric diagnosis,
had not visited any psychiatrist and was not prescribed with any medications related to the same.
She denied of having Mania, psychotic symptoms, hypomania or depression previously.
Family Psychiatric and Medical History
No kind of formal psychiatric diagnosis was found in the history of Anna's family. However,
according to her beliefs, her grandmother as well as mother suffered from excessive health and
anxiety concerns which were not fixed by test results and normal examinations from their
respective general practitioners. There was no history of suicide in her family.
Past medical history
Any kind of significant medical history was denied by Anna. History of TOP in 2015 and
rosacea was provided by her general practitioner. A more detailed medical history has been
provided in session 2 by Anna. She was only able to recall minor health issues from her
childhood which required medical attention. As an infant, she suffered from croup and was
provided with treatment in hospital. At the age of 4, Anna had fell off from the balcony of a one
storey, however suffered from no fractures. At the age of 9, she suffered from appendicitis and
required appendectomy. She wore braces and was required to remove a number of teeth.
According to her, she was a happy child.
Medications

As instructed and prescribed by her general practitioner, Anna has been using propranolol 10 mg
PRN for once or twice in a week before her performances. A Mirena IUD was inserted in 2015.
She was also prescribed with a Ceased diazepam PRN.
Substance use history
Alcohol was consumed by Anna more than what was specified by the guidelines of NHMRC.
Currently, she consumes an average of 3 to 4 drinks every night, and in a week she does the
same for 3 nights. This has been a routine for the last 4 years. According to her, she has reduced
this consumption in the last month after her review with Dr. Wyatt. During the 2 week period of
het review with the doctor, any kind of withdrawal symptoms were denied by her. It was
admitted by Anna regarding her over consumption of alcohol than that of the recommended
levels and also expressed a desire for reducing the same. As described by her, alcohol helps in
reducing anxiety, however she did not use the same before her performances. She had no craving
for alcohol and there were no significant effect on our health. Her parenting was also not
impacted since she drank with her husband after her children had gone to bed. Any kind of abuse
of prescription medications were denied by her. Benzodiazepines were used by her whichwere
prescribed by her general practitioner.
Personal history
Birth and development

Anna was born and raised in the inner east and the inner west of Sydney* respectively. She was
the only child of her parents, and throughout her childhood she lived with her parents and
grandmother.
Childhood
It was reported by Anna that she usually was a well and happy child would like to play alone.
She admitted that she often felt out of place while she was in primary school which was greatly
due to the intervention of a mother in her clothing and attendance on the basis of her health
concerns. However, Anna tried to overcome this while she was in high school since she wanted
to make friends. She admitted that she disliked and tried to avoid conflicts wherever possible.
Family members and relationships
Father
Her father was an architect and mother was a house wife. According to Anna, her father was a
rational, scene and lovely person. She had a great bonding with him and was significantly
supported by him.
Mother
She described her mother as a shallow, fearful, jittery and detached person. She did not share any
kind of bonding with her and explained her as an anxious hypochondriac person.
Husband
Anna described her husband Tom, as a supporting, caring and loving person. He was on full-time
household duties as Anna herself was the primary financial provider oh the house.0020
Forensic history
Any previous court hearing for criminal charges was denied by Anna.
Occupational history
Anna worked as a full time freelance performer and enjoyed her job. In her house, she was the
primary financial provider.

Social history
According to Anna, she enjoyed and loved her work. She took pride in her success. In her
family, Anna earned more than her husband of which she felt very proud, and hence they decided
upon the husband being a full-time parent and staying at home. She liked to catch up with her
female friends, exercise daily and spend quality time with her children. In order to reduce stress,
she attended gym an indulged into high energy aerobic classes.
Mental state examination
Appearance
Anna is presented as a woman of pale skin, small build, stated age and short wavy dark hair. She
wore minimum makeup, usually dressed up in casuals and jeans, exhibited good hygiene, and
wore block heeled shoes. She did not have any pierces or tattoos on her body.
Behavior
With her family, Anna was a co-operative and polite person. She explained of engaging easily
and maintained a good eye contact with people. However, at times when she recalled traumatic
events, she seemed to loom away.
Speech
The speech of Anna was spontaneous with normal variation, tone and rate. She was comfortable
in raising her voice while expressing anger and her tone would lower down while expressing
sadness.
Mood
Her mood usually remained good however; the same became somewhat anxious during a
meeting with a new doctor.
Thought
She possessed a linear and logical thought form and was able to maintain a continuous narrative
even while discussing her trauma.

Perception
No reports or evidences of hallucinatory phenomena were found.
Cognition
Anna was quite alert in general, and had good orientation towards people and places. She had a
good memory and concentration, however, some instances such as visiting a new doctor or
performing at stages in front a lot of people often made her lose focus.
Insight
She had a good insight into the quality and nature of symptoms. Significant judgment has been
exhibited by her in seeking proactive treatment, engaging into review and reducing her alcohol
consumption.
Judgment
Anna’s judgment was unimpaired.
Physical Examination
A physical examination of Anna was completed by her general practitioner. A normal range of
psychomotor activity was exhibited by her. No psychomotor agitation or abnormal movements
were recorded.
Formulation
Anna was the forty five year old woman, who was married and had 3 children. She worked as a
full time freelance performer. She suffered from panic attacks and social anxiety disorder of
which she held a history of 22 years. She also suffered from binge alcohol usage.
The criteria for the disorder of generalized anxiety and panic disorder that was not fulfilled by
her. The criteria for other specific in society disorders were not fulfilled either. No kind of
psychotic symptoms were experienced by her.
The symptoms which Anna held had occurred on a background of genetic predisposition to
health anxiety's early modeling and anxiety by her grandmother and mother.

Evidences of significant difficulties of attachment were found related to Anna and her mother.
The psychological vulnerabilities exhibited by Anna resulted from the difficulties during her
developmental stage which can be described as personality structure of the cluster C.
In spite of the issues, the trauma was used by Anna constructively for driving her career and
attachment parenting style.
Furthermore, new suicidal, self harming tendencies were found in Anna. She found herself to be
well supported by her husband and had a good bonding with the children.
The primary objective of the psychodynamic therapy would be to be placed at the place of the
mother, Hold and hear the anger of Anna and allow her for stepping towards the depressive
position. The other part of the work would also be to assist her for acquiring the ability of
regulating her own impact without dress using to her safety behavior and helping her in
improving her self esteem. It would also include helping her to reduce her fears of rejection and
shame.
Diagnosis
The symptoms of Anna were considered to be mild as they affected only about 10% of the
performances. However, it was required by the DSM criterion C that fears or anxiety was always
provoked by the social situations. The full criteria for diagnosis of alcohol usage disorder were
not met, even though the disorder was considered. Anna had been working up on reducing her
alcohol consumption. However, the amount consumed by her is still above the recommended
levels.
No evidence of cluster C personality structure was found. Out of the seven criteria for the
disorder of avoidant personality, Anna met 3; however, in order to conduct a diagnosis, a
minimum of four criteria should have been met. Hence, the required number of criteria was not
met for the disorder of avoidant personality.
No evidences of secondary or comorbid major depressive dysthymia or disorder was found. The
criteria for other specified disorders of anxiety was not fulfilled either. No current symptoms or
history of mania or psychosis was found. Anna had certain low acute risk issues. The primary
risk was the usage of alcohol.

Anna had suitability for psychotherapy. She had the potential of benefiting from CBT for getting
rid of the disorder of social anxiety. She could also be a good candidate for the psychodynamic
psychotherapy.
Management Plan
I furnished the details of the past history of Anna with reference to her treatment. The aspects
which were taken into account are as follows:
Medication
Appropriate antidepressants have been prescribed for Anna as far as the course of her treatment
is concerned. However, she has expressed dissatisfaction since none of the antidepressants have
hitherto helped her in the long run. Additionally, some of the antidepressants have caused side-
effects to a massive extent. As a result, her general practitioner suggested the alteration of the
course of the intake of such antidepressants which helped her to recover to a certain extent as far
as the improvement in mental health is concerned. This led her general practitioner to continue
prescribing the antidepressants on a periodic basis taking account of her signs of recovery and
improvement as far as her moods are concerned depending upon the situation in question. Her
present medications are inclusive of ten milligrams of Propranolol and 2 milligrams of
Diazepam.
Psychotherapy
The kind of psychotherapy involved in her treatment was the short-term dynamic therapy. Such a
therapy implies the principles related to psychoanalysis in order to formulate an understanding
with reference to the attraction of patients and clients at the sessions related to the concerned
therapy. Such a therapy involves forty sessions thereby resulting in motivation with reference to
the prevention of avoidance (Prochaska and Norcross, 2018). It also includes interaction in a
flexible manner as far as expression is concerned. Additionally, the aspects of interpersonal
relationships are to be improved as a result of the Levels of Personality Functioning Scale DSM-
5 alternative models of personality disorders in order to provide an opportunity to Anna for
identifying her actions relating to the situations concerned with reference to the addressing of the
issues relating to the making of conversations with others. It would help in the improvement of

her relationships with her near and dear ones in a more proper and appropriate manner as far as
the ability of solving problems is concerned with reference to the overlap with stability as far as
the psychosocial aspect is concerned.
The Psychotherapy Supervisor Dr. Voss concluded that the Object Relations Model would be
quite suitable for the psychotherapy treatment of Anna. Such a model has been opted for as it
appropriately relates with the psychodynamic aspects of the case as far as the mental health
status of Anna is concerned in relation to the chain of events. Apart from the Object Relations
Model, the other alternative models which have been recommended by Dr. Voss include
Conversational Model which implies the identification of disruptions in communication thereby
presenting signs of disassociation and subsequently being re-engaged in the conversation
concerned. The model related to Development as a result of self-psychology has also been
suggested by Dr. Voss as far as the empathetic aspect to be utilized is concerned. He has also
deduced that the attachment theory can also be applied in the course of Anna’s treatment as it
implies the addressing of all the issues related to psychotherapy. The model concerning insecure
attachment was also suggested since Anna claimed that her mother did not leave any room for
her privacy thereby leading her to undertake measures related to protection from the invasive
approach of her mother as far as her personal matters are concerned. The model concerning the
avoidant personality disorder has also been taken into account by Dr. Voss as far as her
relationship with her husband is concerned. It has been reflected that Anna had been angry with
her mother on a constant basis thereby resulting in the conditional situation implying to be either
comply with the demands or do not maintain any relationship (Germer, Siegel and Fulton, 2016).
During her consultation with Dr. Butler, she was referred to Dr. Brennan as far as specialized
treatment in the area of psychotherapy as far as family therapy is concerned. The outcome of
treatment with Dr. Brennan resulted in a letter to her General Practitioner Dr. Andrews which
implied that her treatment with Dr. Wyatt concluded that she had Social Anxiety Disorder for the
last twenty years. She was referred to Dr. Wyatt by Dr. Andrews on grounds of Generalized
Anxiety Disorder as concluded by her General Practitioner Dr. Andrews with reference to her
present medications and past medical history. It has been suggested by Dr. Butler in his letter to
her General Practitioner Dr. Andrews that forty sessions of psychotherapy are necessary for
Anna as far as her recovery is concerned (Berne, 2016). It has also been noted from the letter by
Dr. Butler that Dr. Voss would be supervising him during the sessions of treatment relating to

psychotherapy. The psychotherapy has been recommended in order to ensure that the risk factors
related to mental health are prevented. Such risk factors are inclusive of chronic addiction to
intoxicating substances, tendency for committing suicide in a dangerous manner, displaying of
hallucinating symptoms and the furnishing of aggressive behaviors as far as destructive and self-
destructive signs are concerned. Such an option of psychotherapy seems to be right as it would
help in the derivation of a comprehensive solution in an effective and efficient manner as far as
the diagnosis of Anna is concerned. It would subsequently lead to the recovery of Anna in a
proper and appropriate manner as far as the long run is concerned. It has also been observed that
the psychodynamic aspect of psychotherapy has proved to be quite beneficial for various patients
having mental health problems in comparison to the cognitive behavioral therapy.
As a result, Anna agreed to undergo forty sessions of psychotherapy by providing her consent for
the same in the interest of her clinical treatment in a proper and appropriate manner. The sessions
were conducted in an amicable manner in order to ensure that she feels comfortable during the
sessions concerned and does not experience any hassles or hurdles thereby presenting her
grievances in a proper and appropriate manner as far as the finality of her treatment is concerned.
Assessment of Suitability for Psychotherapy
Through various reliable sources and reasonable findings, the techniques relating to
psychotherapy were applied. The reason with regard to the referring of such sources and findings
was to capitulate and elucidate upon the treatment of Anna (Berne, 2016). The signs displayed
by Anna for the suitability of psychotherapy are described as follows:
Health-sickness dimension
There are no signs on part of Anna with the risk of harming others or self as far as violent
behavior is concerned. Additionally, there was also no prevalence of personality disorder at a
huge level in her as far as regular mood swings are concerned. Such signs cause severe
impediment in treatment and diagnosis thereby resulting in the hindrance relating to the
implementation of psychotherapy. Furthermore, the Cognitive Behavioral Therapy has not
helped Anna to recover herself in the long run as far as her symptoms relating to Social Anxiety
Disorder are concerned. The forty sessions prescribed to be conducted as a part of the treatment

of psychotherapy in a complete manner may also be difficult due to the presence of the aspects
of possibility to cause harm to others and self as far as proper diagnosis is concerned.
Psychological dimension
Anna was having Social Anxiety Disorder based on her past experiences as far as difficulties
involved in the engagement with people are concerned. As a result, she made introspection in the
chain of events happened in the past and subsequently linking these events with the current
instances. She fully participated in the consultations which helped the doctors to conclude upon
the findings and diagnosis in an effective and efficient manner as recommended by her General
Practitioner Dr. Andrews. She expressed her keenness with regard to the undergoing of forty
sessions of psychotherapy which is one of the essential elements comprising of the treatment
related to psychodynamics (Fox, 2017). Her characteristics do not imply that she would possibly
display behavior which implies impulsiveness as far as destruction to oneself and others is
concerned. It is also imperative that Anna wants discover herself as far as forging of
interpersonal relationships with her near and dear ones are concerned.
Therapy dimension
It is essential to implement therapeutic aspect as far as the treatment of Anna is concerned. It is
imperative that through therapy, Anna would be helped to form interpersonal relationships with
her near and dear ones in an amicable manner as far as the addressing of the issues related to
Social Anxiety Disorder is concerned. It further implies that her relationship with her mother and
her husband Tom would be improved as far as the proper treatment relating to the therapy to be
applied is concerned taking account of the signs of recovery and improvement by the virtue of
the various sessions and consultations (Foulkes, 2018). It is also observed that Anna understood
the importance of undergoing therapeutic treatment as far as recovery and diagnosis are
concerned. As a result, she agreed upon the forty sessions of psychotherapy to be conducted as
far as the full course of the treatment is concerned.
Goals of psychotherapy
The primary objective of psychotherapy is to alleviate the emotional pain by improving one
better (Carkhuff, 2017). In addition, it helps in developing better understanding as well as in

solving of psychological issues. As per the case study, Anna was anxious regarding her job
performance and she had conflict with her mother since she had hypochondria. Therefore, she
consulted a psychotherapist. In order to minimize the anxiety, psychotherapy is beneficial, with
which the patient can cope-up with the day-to-day life. This long term medication is framed in
such a way, so that the patients would get relief from the symptoms. The psychologists are
specialized in dealing with the anxiety disorders and they usually suggest to do cognitive-
behavioral therapy (Shedler, 2010). This therapy is significant to determine the factors, which
increase the anxiety. Based on the weekly session, which is conducted by the psychotherapist
trainee for Anna, it can be stated that deep conversation with the patient is capable to minimize
the disease and can improve their mental state. In a nutshell, the psychotherapy would be
effective to make one confident by reducing her anxiety (JongsmaJr, Peterson and Bruce, 2014;
Shimokawa, Lambert and Smart, 2010). On the other hand, it would lead to maintain a good
relation with the near and dear ones. She can happily enjoy her life and can successfully deal
with the work load, which would in turn improve the performance of her.
Supervision and learning goals
I am presently working as a trainee in psychology thereby providing consultancy services to
patients on a preliminary basis taking account of their past reports and undertaking the next
course of action as far as referring them to the appropriate supervisor is concerned. In my
experience, I have observed that the engagement in activities relating to psychotherapy would act
as an essential learning opportunity as far as growth and development in terms of career at the
personal level is concerned. Such an experience is also helpful in the honing of skills which must
be possessed by a psychiatrist. It has also made huge modifications with regard to holding
various kinds of perceptions and apprehensions. For example, I have learnt to be more non-
judgmental while conducting sessions for patients thereby making them feel more comfortable in
presenting their grievances in a proper and appropriate manner so as to derive an appropriate
conclusion as far as their diagnoses are concerned. I have got to know more and more patients
during my stint as a trainee thereby delving into their matters as far as psychology is concerned. I
have also learnt the different techniques to be applied for different patients during their
consultations and counseling sessions with regard to their treatment in an incredible manner. I
have also got to know that different kinds of medicines are to be prescribed with reference to the

psychological disorders in question depending upon the circumstances which led the patient to
seek help in order to redress their issues related to mental health at the clinical level. My
supervisors have also been quite helpful in providing me with the appropriate guidance as far as
clinical trials are concerned with reference to dealing patients in an amicable manner thereby
undertaking a humanistic approach with regard to the delving into the rationale behind their
mental health problems. I have gained hands on experience in dealing with mental health issues
and addressing them in a proper and appropriate manner as far as the satisfaction of the patients
is concerned with regard to the remedial measure in a proper and appropriate manner. The
therapeutic approaches related to psychiatry must be conducted in an extremely meticulous and
cautious manner so as to make conclusions and recommendations with reference to the further
actions to be undertaken for the patient concerned. From the theoretical concepts as suggested by
my supervisors, I have also observed the appropriate methodologies and approaches which are to
be followed while conduction the sessions of patients as far as the comprehension upon their
treatment is concerned. As imperative from the case of Anna she had issues not only with her
family members but also at her workplace as far as Social Anxiety Disorder is concerned. She
did not experience comfort amongst crowds thereby not being able to fit in. However, she
displayed signs of improvements during the sessions conducted with regard to the counseling in
terms of psychotherapy. As a result, she was able to cope up with situations involving crowds
such as parties, get-togethers and functions in a better manner. It is imperative that the forty
sessions as a part of her psychotherapy treatment are essential as far as the addressing of mental
health issues is concerned. These sessions have also helped her in the improvement of her
relationships with her parents even though issues still remained with her mother. As a result, it is
imperative that there has been a considerable progress with regard to her sessions concerning
psychotherapy. It further implies that the forty sessions for Anna has worked quite well as far as
her mental health is concerned. It is also observed that such forty sessions are quite essential for
a patient undergoing treatment related to psychotherapy. The chain of events with regard to the
circumstances must be taken into account as far as the welfare of the patient is concerned. I have
also learnt the derivation of conclusion related to the further treatment for the concerned patient
taking account of the past medical history of the patient relating to the mental health condition
and the action to be undertaken accordingly. However the recurring aspect of anxiety must also
be taken into account.

Setting and frame
The session took place in the nearby administrative building since I have specialization in the
psychiatry department. I have knowledge to deal with the societal anxiety of the patients. I was
responsible to organize the entire sessional psychotherapy for Anna; however, I had been faced
difficulties in maintaining consistency with the room arrangements. In order to make the
sessional weeks successful, I was focusing more on maintaining calm, peace and predictable
environment in the room. I required to assure my supervisor that I would not be disturbed during
the weekly session. I needed to behave with Anna in very gentle way.
Before starting of the weekly session, I assured Anna that the privacy would be maintained. All
of the information would be confidential and no data would be leaked. In addition, I would not
interact with her husband, Tom, until Anna would give me permission. Based on the progress of
the weekly session, I informed Anna that 40 psychodynamic psychotherapy sessions would be
conducted. If required, then the sessions would be stressed more. I was always trying to motivate
Anna and also not to take additional work load, so that the anxiety can be minimized. In addition,
for improving the relationship with her mother, always try to motivate her to spend more time
with family and do not need to engage in conversation with her mother, so that unavoidable
conflicts would occur. I also informed Anna that if any session would be cancelled, then I would
call her up and would fix it to another date. Each of the session would be of more than one hour
duration, so that we can interact with each other and I would be able to know about her problems
in details, so that I can instruct her towards the right path.
Progress: Summary of Psychotherapy Sessions
Session 1-5
In the first session, I have started to talk casually with Anna; she had come to me to discuss her
problem. As per the discussion, Anna is 45 years old lady, who is living with her husband and
three children. She has been suffering from performance anxiety and also for addressing conflict
with her mother and hence, she would like to consult psychiatrist, otherwise she would engage in
suicidal case or would do self-harm behavior. Initially, I had found a social anxiety disorder due

to the presence of psychological vulnerabilities. In the starting of the diagnosis, Dr. Wyatt had
asked her to minimize the alcohol consumption. In addition, I had suggested her to use
Propranolol of 10-20 mg. However, her anxiety was managed by psychodynamic psychotherapy.
For the further process, I had done mental state exam of Anna, with which I would be able to do
better diagnosis.
In the second session, Anna informed me that the first session was effective, which helped her to
improve her work performance level without creating any issue. More specifically, she was not
feeling anxious or required PRN medication after that session. However, she informed me that
her conflict with her mother regarding her mother’s hypochondria would lead to create social
ostracization and it would make the situation of anxiety worsen. In order to improve the
psychological behavior, I had given her homework to supervise her thoughts during social
triggers as well as also required to consider the underlying core beliefs (since Anna had negative
beliefs about herself).
During the third assessment, Anna informed me that her psychological behavior has been
improving day by day and she used to start more time with the family members. It would in turn
make her more socialize; she got less time to think about her negative beliefs. She took
propranolol prophylactically only before two performance, so that the unavoidable anxiety could
be triggered. However, she still admitted that she had lots of anger towards her mother. In order
to address the developmental trauma, I also suggested to rely upon SAD (social anxiety disorder)
or CBT model apart from following the psychodynamic psychotherapy.
In the fourth session, it can be observed that expertise, Professor Scott and psychodynamic
supervision specialist Dr. Voss would do the treatment of Anna. Though, Anna had reduced the
alcohol consumption by 1-2 SD per day, however, she needed to use propranolol PRN, so that
the psychodynamic conflicts would be addressed. In this session, I have tried to focus more on
the relationship between Anna and her mother, so that it would be improved. At the end of the
session, I have decided to continue the weekly psychodynamic psychotherapy since Anna was
not concerned about her father’s absence, instead of it; she was highlighting only the form of
negligence of her mother and grandmother. It would not eradicate conflicts between them.

Anna entered in the session 5 with her smile, which implies that she was pleasant with the
progress of this weekly session. In the previous session, I had asked Anna not to contact with her
parents, so that the conflicts or anger on them would not be increased more. Therefore, Anna
informed that though, she had spent a good week with her husband and children, she did not
communicate with her parents. In addition, she also asked her husband not to show her their
emails. Though, her father sent a mail by stating sorry, however, she was getting impulsive and
replied back very badly. Therefore, she found that her situation was going to worsen situation.
This was the reason of continuing the weekly psychodynamic psychotherapy.
Session 6-10
Session 6 was an unusual grooming section. However, in the introduction, Anna stated that the
last week was very tough to her regarding the email reply and interaction with her father. As a
result, she was suffering from sleep disturbance. It would in turn increase fatigue and exhaustion
and her communication with father would be increased. This would refer that she was concerned
about her father and wanted to improve the communication with him. Then I suggested her to
stop communicating with the family permanently and also to cut off the relation, nonetheless,
Anna said that it was not possible since her parents were living close to her house and would try
to communicate with them constantly. I thought it would be effective since she had sympathy for
her father’s pain, and this was the repercussion of her sorrow and sadness towards her father. It
would be suggested that the weekly psychodynamic psychotherapy would be continued.
In the seventh session, Anna informed me that she had a pleasant weekend and had fun with her
friends in Melbourne. Since, in the last week Anna became much emotional, therefore, my
supervisor suggested me to frame open ended questionnaire for her irrespective of directive
approach. As a result, she would get freedom to express herself more safely and did not need to
talk about her mother’s madness and her anxiety. I also asked Anna to discuss only that much,
which she wanted to tell. Anna informed that for reducing the conflicts among two families,
Anna wanted to maintain a distant connection, whereas her family wanted to make a happy
family instead. Since, her mother was not close to her, therefore, she would not feel anything if
her mother would die and it would refer that as per the suggestion of my supervisor, this therapy
session was not efficient. In spite of it, I needed more time for regrouping.

In the starting of eighth session, Anna mentioned that she had come there by public transport and
it was fun to her. The discussion was started completely differently compared to the last session
and she described about her journey and experience. Suddenly, after sometimes she started to
talk about her mother. However, Anna said that neither her anger was so high, which was more
before 3-6 months nor she felt extreme sorry, rather she was more objective. In addition, in this
session I found a new sight in Anna since she started to talk about the positive sides of her
mother. This refers that if hypochondriasis within her mother would be absent, then the
relationship between her mother and her would be improved.
In the starting of ninth session, Anna informed that the discussion of last session made me happy
and she decided she would open her up more for discussing about the positive sides of her
mother. My supervisor had found out a similarity of this situation with Melanie-Klein’s theory
and he also said that if her mother was not at all bad, then Anna was not so good. In order to
improving her state, this weekly psychodynamic psychotherapy would be continued.
Anna had described the last week as “mixed week” in the session 10, since, her performance
anxiety has increased. This happened since she was exhausted and would not be able to sleep
deeply due to her son had nightmares. Though, after taking of PRN propranolol, her anxiety was
vanished, which had come unexpectedly and suddenly with the time. Therefore, I suggested her
for self-care. I have a perception that her nature of anxiety would affect her children. It might
increase the stress level. In order to minimize the anxiety of her son, Anna arranged occupational
therapy classes. Therefore, this discussion would be continued in the next psychodynamic
psychotherapy.
Session 11-15
At the starting of 11th session, Anna informed that she did not yet contact with her father. She
also stated that she had spent a busy week; however, she was capable to manage her anxiety even
without using of PRN propranolol. She also added that she had become more confident in the
current weeks, even her harsh ego had getting softened. It would in turn minimize the occurrence
of catastrophe. The psychodynamic psychotherapy would be continued.
In the 12th session, Anna also stated that she did not contact to her father and thought that
whether she had overcome or not her anger. Anna also informed that she had achieved perfect

reconciliation and used to respond in the passive aggressive attitude. Since, Anna’s parents did
not ever acknowledge her; therefore, she wanted to feel secured to her children, so that they
would not feel same problems. She and her children are very close to each other, completely
opposite of her mother. In this week, I found that Anna’s anger towards her mother had been
dissipates gradually and she was concerned about losing weights of her mother. For further
improvement, this psychodynamic psychotherapy would be going.
The session 13 was cancelled by Anna herself since she was not feeling well. Therefore, this
would be conducted o different day. Though, it was difficult for me to find out another time for
her, however, these weekly sessions are very important for her and it would be needed to
continue it for next three weeks.
The 14th session was conducted after 3 weeks of gap and Anna stated that she spent amazingly
these 3 weeks. As per the discussion, it can be found that Anna’s parents are manipulative,
nonetheless, the estrangement had been sustaining for many days. However, after 13th session,
Anna found that she wanted to reign her parents as she did not like confrontation. She stated she
was protected under the barrier; however, she was not at peace. This psychodynamic
psychotherapy would be sustained.
Anna stated in 15th session was that she spent not a too bad week like to the previous week. In
the last week, Anna was capable to overcome her anxiety even before her performance level.
Anna was also very surprised about her progress since she did not expect how it go fast.
However, she also told in this session that her mother was weird, and she was not at all a bitch,
this had led to make a bad relationship between her and her mother. This would in turn refer that
though she had started to be softened towards her parents, nonetheless, she would not be able to
forget about her past and hence, I had decided that this weekly session would be continued.
Session 16-20
The 16th session of Anna was started by saying that her last week was eventful. She informed that
her mother’s number still was in the block list; therefore, after returning home from the work she
got the news of her father’s heart attack. Therefore, Anna was ashamed of and felt guilty. After
that Anna unblocked her mother’s number and apologized. After a certain time, Anna’s mother
contacted her and she was very happy for that and also asked to call her father tomorrow. Anna

stated that hence, the last week was stressful to her. At the last, Anna mentioned that she would
call her father before the next session. Hence, the next psychodynamic psychotherapy would be
continued.
In the starting of 17th session, Anna said that she did not call her father however; she interacted
with her through texting. She also informed her father was mentally fit though he was physically
unwell. On the other hand, Anna also started to talk about her mother’s weird attitude towards
her. She mentioned that her mother used to support her in a weird way. During the discussion,
Anna informed that she had kept five days’ time for family in Tasmania. This was the
implication of her progress and hence, I had decided to continue this weekly psychodynamic
psychotherapy session.
In the starting of session 18, Anna informed that she did not do many things in the previous
week, on which she can discuss. Mainly she was busy to manager her works before going to the
family holiday. This would in turn help her not be anxious since she was busy with her works.
However, she stated that the misunderstanding between Anna and her father had not resolved.
Therefore, she inadvertently returned back to CBT mode. It might be capable to reduce her guilty
feelings as well as the nature of betrayal. It would in turn pop into her head every day, even
during the family holiday time. However, Anna’s father contacted her and asked her to call him
up anytime. This had influenced Anna to finish the chat with the reply “Love dad”. In order to
determine the fluctuations in her emotional stages, the psychodynamic psychotherapy would be
continued in the next sessions.
This session was conducted after two weeks of the previous session, since Anna went to
Tasmania for family holiday. This holiday was not only the kid’s holiday, but also there were
lots of walking, eating as well as catching up the friends. However, she did not get much time to
call her father before going to the family holiday. This was the reason, why Anna felt guilty
during her family holiday. After returning from holiday, she called her father for 15 minutes.
Initially, Anna thought that her father would be depressed on her; however, he spoke with her in
very gentle manner. After the conversation, they have planned to meet and go for coffee. This
was the implication of good progress. In addition, Anna made a good eye-contact, which would
in turn positively influence the therapy. After finding the progress, it could be decided that the
psychodynamic psychotherapy would be continued.

In the starting of the session 20, Anna informed that her mother made her upset again and also
tried to ignore her boundary. However, Anna also stated that during her father’s absence, she
needed to cope up with her mother. Being a single child, she would need to take all the
responsibilities of her mother. On the last, Anna said that her physical symptoms of anxiety had
been reduced and in taking of alcohol had also been decreased. From this point, it can be
mentioned that her anxiety had been recovering and this was the reason of continuing the
psychodynamic psychotherapy.
Session 21-25
When Anna has come to attend session 21, then she stated that nothing has much changed and
hence, frustration would be reflected in her voice. She again started to complain against her
mother. Therefore, Anna wanted to conduct a treatment and therapy for minimizing frustration.
This was the reason, why she wanted to meet her father alone and not wanted to meet her
mother. However, her anger towards her mother had been declined from the previous situation.
In between the discussion, Anna informed that her trauma was equivalent to those, who were
sexually and physically abused and it was the implications of being neglected since her
childhood. The psychodynamic psychotherapy would be continued.
At the starting of 22nd session, Anna was in hurry to inform about her meeting with her dad.
Apart from the casual discussion, Anna’s dad expressed some concern for her mother.
Nevertheless, Anna said him that being angry; she did not want to be connected with her mother.
However, Anna anticipated that her mother was fine. In order to build a good corner in Anna’s
heart regarding her mother, her father tried to share with her about the childhood memory. Still
Anna was not able to empathize her mother. Then her father said that her mother felt sorry for all
her misdeeds towards Anna. The conversation with her father would lead to reduce her anger for
her mother. In this session, the guidance of my supervisor also helped me to be comfortable,
which had helped me to bring her feelings and emotions successfully. Therefore, the sessional
conversation with Anna would be continued more for understanding her in better way.
Anna informed in 23rd session is that from the conversation with her mother, she had come to
know that her father started to recover in ICU. However, Anna did not want much to talk with
her since she was still upset. From the ICU, Anna’s father tried to make conversation with her

and also tried to convince her. He requested Anna to send messages to her father. Thus, Anna
said that she was angry throughout the week since she needed to make her mother happy. In
addition, she also required to move to her mother since her father was in ICU. Anna wanted to
hurt her mother. Therefore, I required recovering Anna and bringing her back in normalizing life
and hence, wanted to continue this weekly session.
In the starting of session 24, Anna said that the last week was ok and she was little bit upset.
After going to gym, her mood was started to improve. In this session, it can be seen that her
anger towards her mother would not be reduced. On the other hand, she also informed that she
wanted to improve the relationship with her mother. However, she also hated her and also
wanted to punish her mother for all her mistakes. She also mentioned that Anna would like to
show her emotion, however, it had come out as tears. Therefore, it can be mentioned that her
emotional mood swing would needed to be observed more and hence, the weekly
psychodynamic psychotherapy would be continued.
In the 25th week, Anna mentioned that she had spent a pretty good week. More specifically, it
was equivalent to the emotional problem of previous week. In addition, in the last week, Anna
was without of alcohol for two nights. On the other hand, Anna tried to call her father; however,
he did not pick up his call. Hence, she had left voicemail to his father. Furthermore, it could be
stated that Tom was frustrated with the events. It referred that her family was suffering from
anxiety, which would in turn affect the job performance of Anna. Therefore, the psychodynamic
psychotherapy would be continued.
Session 26-30
In 26th session, Anna said that she had spent a pretty good week since; she did not take alcohol
for last five days. In addition, for reducing her anxiety, Anna focused more on the reading and
sewing. She identified these as the productive relaxation. Anna stated that she is now capable to
control her harsh ego as well as can improve her self confidence level, which has been reflected
in his personality traits. However, she also added that she is still sensitive.
The 27th session was started to talking about Anna’s friend, Kate. After that she said that she had
stuck in between of false-self and emotional response. In this connection, I also briefly explained
her about mentalisation. At the last Anna was getting shocked since 27th session was running.

She was also getting nervous that whether her problem would be solved since it had not totally
solved till the current session. Therefore, she told that Anna would do based on the paperwork.
This way the sessional psychodynamic psychotherapy would be continued.
Anna believe that after 27th session, she had actually spent a good week, which had stated in 28th
session. She had continuously taken her father’s news and how was he recovering. Suddenly,
Anna’s mood started to swing and she moved towards the depressive position since her father
constantly forces her to talk to her mother. Hence, Anna had decided that she would ask her
father not to force her. She also planned to behave like more strongly instead of being more
anger or anxious. At the end, Anna mentioned that her past experience made her strong, which
would lead her to be a bad parent since; she had already extracted the best from her childhood.
The conversation would be continued.
Anna was busy in the last week in the preparation of Christmas party. Therefore, in the starting
of 29th session, she had informed that she was suffering from anticipatory anxiety and
consequently, she had taken one propranolol. In the last week, the work load was also very high;
therefore, Anna was suffering from stress. However, she was not anxious and she was able to
protect her by increasing her nature of self-esteem. Due to having of huge pressure, Anna could
not be capable to spend time with her children. However, for keeping her motivation high, I gave
her positive feedback for Anna’s children, so that she could reconnect with her children. This
way the weekly session would be going.
The 30th session was the final session of the year 2017 and she would get two weeks break before
of Christmas. Anna gifted me mini desk calendar and chocolates. On the other hand, I have
found that Anna’s obsessional traits have been softening with the passage of time. In this
context, it can be stated that Anna was calmer to be herself and she could deal the pressure in
maintaining of positive impression. At the end it can be observed that Anna has been improving
herself. Therefore, the session would be continued.
Session 31-35
This session was started after the two weeks break of Christmas. She started to describe how she
had spent her Christmas. In addition, she stated that she was cautiously happy since her father
sent her a virtual birthday card instead of giving it in hand. It was the reflection of improving the

relationship between them. Moreover, the behavior of her father has been changed over time and
she also started to respect her father. Apart from this, Anna also received a birthday wish through
text from her mother. Suddenly, Anna mentioned that she did not want such wish from her
mother. Instead of, Anna would be happier if her mother acknowledge her current tension or
would show sincere feelings to her, it would be more convincing. Similar to the previous session,
Anna also asked about the future session and stated that she would go another hospital and would
not be able to continue the sessions in long run. In that case, she could consult local private
psychotherapist if required.
Anna reached 15 minutes late in session 32 for huge work pressure. In the last week she had
spent a nice trip with her friend Ava. She also informed that she was thinking about the last
dream, which in turn implied the path of her sessional therapy. Her dream was more fascinating
instead of stressful. Suddenly Anna asked me to discuss about the pressure of Christmas. During
this time, her parents tried to contact her during such pressure of this festival. This would lead to
create dilemma that whether she would need to reconnect or require to unresolved the matter. It
was the emotional load to her.
In the 33th session, Anna informed that she had joined a gym. In the last week, Anna mostly
thought about the maternal introjection, which was discussed in the last session. However, she
also informed that she was feeling guilt for not fulfilling the societal expectations to show love
and honor to her parents instead of showing rage. Anna was making a list of the unpleasant
things happened with her mother and the incidents were started to increase every day. However,
it can be observed that at the end of the session, her ego has been getting softened towards her
mother. It was the clear reflection of her progress in her behavior. In addition, Anna’s
performance anxiety had also been declined and she was happy since she was able to manage the
things. This was the major reason of continuing the weekly session.
After 33th session, Anna went to a family trip and she had enjoyed a lot, which had in turn
switch off her mood. She also informed that Anna did not pick up the call of her father and
hence, her father left a voice note for her and asked to call him back. Anna said that it was very
annoying since she expected him to understand of not picking up the call. Anna also stated that
she had asked her father to leave a text during the holiday instead of making a call. After that her
father started to call to Tom and asked him to call Anna. Nonetheless, Tom defended Anna and

asked her father that he had heard that Anna had suffered from issues with her mother. Since,
Tom was angry at Anna’s father for his misunderstanding, hence, he was anger at him.
After session 34, Anna had spent a peaceful week in the 35th session. After the last session, she
found that her family would not understand her and hence, she was anxious and thought how to
make them understood. However, she stated that she would not like to build a close relationship
with her mother. In addition, I found that Anna was trying to move towards the acceptance the
relationship with her mother since childhood. This was highly depressive situation of Anna.
Anna was frustrated among the not wanting to talk to her parents and wanting to resolve the
matter and therefore she had been suffering from anger. This was the reason, why Tom
supported her not to hurt her. In this context, I assured her that her mother had been faced the
similar anxieties. Supervisor stated that this view would be supportive to help Anna. Therefore,
the psychodynamic psychotherapy would be continued.
Session 36-40
At the starting of 36th session, I directly asked Anna about her last week. She replied that she had
started to cope up herself with the situation and hence, she was not worried about her parents.
However, she said that Anna had received a letter from her father’s older brother, whom she met
only for five times. The content of the letter was very insulting and he asked to Anna why did not
she reconnect with her parents?” However, Anna did not reply him and saved a letter as a draft
by writing that her uncle did not know her and send the letter only by one side. In addition, it was
mentioned in the letter was that Anna was trying to fix the problem with her mother by her own
style. In order to improve her status, the session for psychodynamic psychotherapy would be
continued and would be continued up to session 40.
Anna had informed in the starting of 37th session that she had spent a pretty good week after the
previous session. I have seen that since the last three weeks, Anna had improved herself and she
would be able to enjoy each of the small things. Anna also said that she had sent the letter by
adding something to her uncle. In the reply, her uncle sent an apology mail to her. After that I
suggested that Anna needed to spend more time with Tom for improving her relationship. On the
other hand, Anna also mentioned that she wanted to meet her parents.

Anna started her session 38 by saying that she had spent a good week and tried to spend more
time with her husband. She had proudly said that she enabled to minimize to intake alcohol and
only had three nights in each of the weeks. Consequently, Anna had started to spend quality
sleep. Furthermore, Anna also mentioned that her mother had some good qualities; however, she
did not have potential to be a good mother.
In the 39th session, Anna informed she was still trying to avoid and to minimize meeting with her
parents. However, I had started to motivate others by giving her emotional and moral support.
For instance, Mia, her daughter was called a slut in Instagram for wearing of ripped jeans and
she dyed her hair in pink color. Therefore, Anna asked Mia to wear those, in which she would be
comfortable. In order to get rid of the problem, Anna asked Mia to delete the application. This
referred that Anna was able to encourage her friend if she would be depressed. In addition, Anna
also told that she was capable to deal the problem of her daughter in better way, how her mother
did with her. Suddenly, in between of the discussion, Anna started to fall into cry since the
sessional psychotherapy was going to be end.
Anna reported in 40th session that she had spent a down week. In this session, she stated that her
frustration had turned into the events and hence, she now wanted to enjoy the last session
thoroughly. In this context, she said that she stuck into the events since she had spent a large time
with them. Lastly, it can be recommended that Anna would need to work hard and need to go to
gym for making her busy as well as to keep away anxiety.
Discussion
Anna informed that she had trust on her own feelings, which in turn made her confident more
after joining the psychodynamic psychotherapy.Anna admitted that the sessional psychotherapy
was going to be end and hence, if required, few additional sessions would be conducted. I would
in turn encourage her, which would in turn lead to spend a stress free life.Apart from the
sessional discussion, it is come to know that her husband, Tom used to do bad behavior with his
children and it is not solved from the sessional discussion process. Supervisor recommended
Anna to contact with Dr. Brennan for conducting further psychotherapy treatment and if possible
to attend the session along with the family as well as also provided a discharge letter to Anna. In
addition, she would need to send a follow up mail after one month for determining the progress

in her behavior which would help in her recovery in a proper manner. Anna also mentioned that
she was capable to deal the situation successfully by her own. In this session, I have clearly
experienced the transformation of power of Anna from a powerless anxious girl to a strong
woman, who has voice instead of getting anxious and worried. In addition, she did not need to
have propranolol for minimizing her anxiety.
Conclusion
The case history of Anna would highlight the usefulness of psychodynamic psychotherapy and
how it would be beneficial to minimize the psychological challenges such as anxiety or the other
trauma of Anna. During the session, I have also learnt how to deal a patient and her problem and
hence, conduct a detailed discussion session. I think it would develop my interest more to
understand the theoretical background as well as the practice of psychodynamic psychotherapy.
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