Dr Belinda Docwra

Advanced Medical Practice

George St

Windsor

NSW 2753

18.06.24

Re: Wendy Hart (DOB: 03.11.1984) Wentworth Healthcare PTS NBM11871 Review

Dear Dr Docwra,

Thank you for referring Wendy Hart for a Wentworth Healthcare PTS plan for psychological support for severe anxiety, depression and complex trauma in June, 2024. I write to provide you with a review at the close of this referral.

Wendy attended the first consultation on the 24th of June, 2024. She engaged well and was able to open up about her past and current challenges. She attended fortnightly consultations, with her review being held on the 12th of August, by which time she had made significant progress. The referral has since been closed.

Initial presentation

At the time of her initial consultation, Wendy spoke of experiencing difficulties throughout her life, that she considered she hadn’t dealt with. She reported a trauma history, from her first relationship at age 19 years, where she was the victim of domestic violence (D/V), including daily verbal abuse, physical abuse and threats to her safety. Wendy left the relationship when their daughter was 8 months old, and the perpetrator was convicted and incarcerated. The experience left Wendy with anxiety and PTSD.

Wendy was subsequently married for 10 years, however, following the break-up of the relationship, Wendy received threats of violence. They had one child together and part of the relationship stress included his not accepting Wendy’s first child and infidelity on his side with a close friend, all of which compounded her trauma and loss of self-worth.

Wendy had always had a close relationship with her daughters. However, at the time of her first consultation, there had been a recent estrangement with the eldest (aged 16), who had moved in with her boyfriend. Her daughter subsequently reconnected with her step-father, choosing to live with him and his new partner, which was difficult for Wendy. These events led to a deterioration in mental health, culminating in an attempted overdose in October, 2023, requiring a presentation to Nepean Hospital. She’d had a previous history of suicidal ideation and an attempt during her first D/V relationship.

Further, Wendy reported current relationship stressors, including a recent break up/separation from her boyfriend (April 2024)

Wendy reported low mood, with loss of motivation and wanting to stay in bed all day. Her life experiences contributed to feelings of “I’m not good enough; I don’t have a voice. She was using alcohol “to forget”, and had had a period of recent cocaine use to feel better, however this was detected on a routine work drug screening, prompting her to seek help.

24.06.24 K10 score: 41/50 – very high level of psychological distress

MSE

Caucasian female dressed in work uniform; clean and well groomed.

Engaged well; good eye contact and easy rapport

Anxiety evident - hand tremor

Talking rapidly, trying to communicate a big history in short time

Mood: anxious; sad; Weeping at times telling of her symptoms

Thought form: logical; sequential

Some insight about impact of trauma history

Good judgement; seeking help to overcome challenges

Formulation

40 year old employed Caucasian single parent with two children, presenting with anxiety and depression in background of complex psychosocial stressors, including history of D/V relationships.

Update

A range of psychotherapeutic interventions were utilised to support Wendy’s recovery. She engaged well throughout and developed insight about the underlying causes of her emotional experiences and strategies to manage them. At the time of her review, Wendy reported a significant improvement. Her mood was bright and reactive, and she was laughing and smiling throughout. She denied suicidal ideation and was more accepting of her daughter’s choices. She stated:

“I’m feeling a lot better in myself; I’m more realistic with expectations. I’ve had no more contact with my daughter, which is heart breaking, but it’s out of my control. I’m in a good place with my youngest daughter. I’m happier at work; I’ve been hanging out with my ex-boyfriend daily. I’m less reactive/triggered.”

12.08.24 K10: 20/50 – indicating significant improvement.

Plan

Wendy utilised all sessions of the plan. At the time of her review, she stated that she felt much better and did not feel the need for another plan at that time. Should she require further support at another time, I would be happy to see her.

Regards,

Michelle Hookham