Dr Vinori Vidanapathirana

Advanced Medical Practice

Windsor

NSW 2756

23.09.2024

Re: Caitlin Rea (DOB: 31.10.1996) Mental Health Assessment

Dear Dr Vidanapathirana,

Thank you for referring Caitlin Rea for therapeutic support for stress and anxiety under Wentworth Healthcare’s PTS program in February, 2024. She attended her first consultation on the 12th of February, 2024 and had fortnightly to monthly appointments, with her review being held on the 23rd of August, 2024. I write to provide you with a review at the close of the referral.

Caitlin had previous referrals to see me in August, 2022, and you will find correspondence for these referrals in your records, including a comprehensive mental health assessment.

Initial Presentation

At the time of this new referral, Caitlin had recently had her second child, Boston, who was 8 weeks old. She had moved to independent rental accommodation with her 7 year old son, Jackson, in November, 2023 and was adjusting to the change. She reported that she had had PND with her first child, however she had been ok with Boston so far.

The main reason for seeking further support was anxiety about the re-opening of legal proceedings regarding sexual assault by her GP in 2013 at the age of 15. She had pressed charges at that time, however the matter was settled out of court. Caitlin was unhappy with the outcome, however moved on with her life, until she heard of another victim to the same perpetrator, which caused her to seek further justice and to ensure he couldn’t hurt other women.

Caitlin spoke of the difficulties the assault had caused her. She reported ongoing mental health challenges since this time. Partly from her own traumatic experience and partly from the injustice of the legal system; that she was accused of lying and felt bullied during cross examination; and that she was not provided appropriate counselling and support throughout the proceedings. She stated “it broke me,” and continues to experience feelings of shame and dirtiness. At the time, she had turned to drugs and alcohol and deliberate self harm to cope with the feelings, and felt that the trajectory of her life had been changed irreparably. She regretted that she was unable to experience affection and touch from her ex-partner, which prevented her from having a healthy relationship with him.

Caitlin reported that she pushed her emotions down and was unsure if she had the strength to pursue the legal matter. However, she was motivated to try, with the hope that it would help her to “find myself again; to get back what he took – my childhood and teenage years.”

Caitlin reported the anxiety was causing her difficulties sleeping and worry that she would lean on previous unhealthy coping strategies to manage (AOD). She wanted to learn to express her emotions, to stop the feeling that she would explode.

Past mental health history

Dx: ADHD in high school Ritalin for short period.

Reports “OCD” since assault, with need to clean ++. This was overcome with previous therapy.

Episodes of DSH after assault.

2017 – sought help for PND

Past medical history (from GP referral)

Asthma

Postnatal depression after first child

PCOS

CIN3 (HPV/cervical cancer)

Supraventricular tachycardia

21.12.2020: Dx depression

AOD

Following the sexual assault and cross examination in court, Caitlin turned to substance use and reported a period of years of polysubstance abuse. She stopped when pregnant with Jackson and has been able to maintain sobriety.

Medication

Stopped antidepressant medication when pregnant with Boston.

Physical health

No current problems.

Update

A range of psychotherapeutic interventions were utilised to support Caitlin’s recovery, with good effect. She engaged well and often said she felt better after talking about it. Progress was interrupted at times as she navigated health challenges with her boys, which she has spoken with you about. Focal areas included:

Strategies to manage anxiety

Learning to feel safe with touch with her children and partner;

Court reports and support during this process

Financial stressor from fines – set up a work development order (WDO)

At the time of her review in August, 2024, Caitlin reporting significant improvement. The outcome of her legal matter had progressed: The lawyers had had to appoint a private detective to locate the perpetrator, to learn that he had moved to Africa, hence unable to be prosecuted. Caitlin stated that she felt more at peace knowing the matter has concluded; that she felt validated that the lawyers believed her. Also, that he may have left the country to avoid consequences for his wrong doing, which also validated her adverse childhood experience. We spoke about the opportunity to pursue a Victims of Crime compensation payment and Caitlin stated that they had been in touch with her.

Caitlin’s improvement is evident in her mood, which is bright and reactive, and her engagement as an active parent, working in canteen. She had just had her first holiday out of NSW and first trip on a plane, and had enjoyed the adventure with her children.

Plan

At the time of the review, Caitlin did not feel the need for further support at that time. She is aware that trauma memories can be triggered by different experiences and will see you for another referral if and when needed.

Her referral has since been closed.

Regards, Michelle Hookham