Dr Toby Taleb Nasr

135 Metella Road

Toongabie

NSW 2146

30.03.2025

Re: Lawrence Attard (DOB: 21.11.1964), Summary of care, review and update

Dear Dr Taleb Nasr,

Thank you for referring Lawrence for a Wentworth Healthcare’s MHNIP’s program in August, 2024 for psychological support for anxiety, depression and suicidal ideation in background of childhood sexual assault. This referral follows a series of Wentworth Healthcare referrals dating back to February, 2019. I write to provide you with a review. Because I have been seeing Lawrence for some time now, I thought I would provide a summary of his presentations, followed by a recent update and plan towards the end of this report.

Summary of presentations and care since 2019

At the time of his initial consultation with me in February 2019, Lawrence reported deterioration in mental health and chronic suicidal thoughts, in background of legal matters arising regarding his being a victim of childhood sexual assault (CSA). He had a history of two previous attempts to end his life, with the previous attempt being in 2017. He had a further deterioration in November of 2019, associated with additional stressors pertaining to the pending legal matters and also financial pressures whilst off work to recover from shoulder surgery.

Lawrence had bilateral knee replacements in May 2021 and had post-surgical complications requiring an additional hospital admission. This prevented him working for 12 months, which impacted his mental health in 2 ways: a) financial stressors and b) lack of meaningful occupation. Lawrence also reported debilitating headaches and continued issues with back pain from past history of motorbike accident.

In July 2022, Lawrence had a further set-back due to relationship stressors and a breakdown of his work truck. He reported a deterioration in mood and was feeling unappreciated. Lawrence experienced a significant deterioration in mental health in September, 2022 following an adverse court outcome, culminating in a suicide attempt on the 26th of October, 2022 and an acute admission to Orange Hospital. Following discharge, he had a period of low mood, with constant ruminations and questions about the trial, the associated injustice and associated lack of acknowledgement and validation of his adverse childhood events. At that time, he reported feeling very tired and was spending long periods of time in bed.

Over the next three months, Lawrence made a slow but steady improvement. He returned to work and was no longer tired all the time or sleeping excessively. He was feeling more optimistic and spent less time ruminating on negative thoughts. He was less irritable and less triggered by family interactions/comments, and he particularly delighted in being a grandfather.

Throughout 2023, Lawrence had periods of doing well with his recovery and episodes of decline, when triggered by life events, such as financial stressors, neighbour’s behaviour with property maintenance, worker’s compensation claim, familial relationship patterns or marital relationship stress. Triggering events caused Lawrence to dwell on adverse life events, which lead to fixed negative beliefs that he is not good enough; not treated equally; is not wanted or valued in the family; that people don’t want him around. A range of psychotherapeutic interventions were utilised to support Lawrence’s recovery. Some proved to be helpful and generated insight, however he continued to struggle with the thoughts.

In November, 2023, Lawrence experienced a set-back in mental health, following his birthday celebration where his brother was given preferential treatment by his father. This highlighted the inequity in relationship between his parents and his brother, triggering Lawrence’s negative self-worth. His mood deteriorated significantly, with increased suicidal ideation. He was referred to the Mental Health Access Team and his medication was increased. Over the following week, Lawrence’s mood improved, his suicidality decreased and he was discharged from the Access Team. Lawrence then engaged in a more intensive weekly psychotherapeutic program, with good effect. Over this time, he was able to explore unhelpful patterns of thinking associated with his trauma history. Lawrence gained good insight into underlying causes of distress and gradually started to improve.

In February, 2024, Lawrence, Esther and I attended a meeting with his lawyers for a debriefing about the outcome of his CSA hearing in 2023. The lawyers were able to provide Lawrence with information about his verdict and answer Lawrence’s questions which had been causing anguish ever since. Lawrence also got to express to the lawyers the level of distress he experienced as a direct result of the legal process and verdict. Whilst it didn’t validate Lawrence’s experience of childhood trauma, it helped him move forward to have this feedback. The level of rumination about the legal matters has decreased significantly since.

At the time of his review on the 12th of June 2024, Lawrence reported feeling general improvement. He had had a set-back the previous week with low mood, however this passed in a few hours after being distracted by a work challenge. We discussed his progress, noting that he is able to move through set-backs quicker and continue to move forward. We discussed trauma theory via a metaphor of an iceberg; that there is still potential challenges under the surface, that could be triggered by family events where he feels poorly treated, or triggers related to CSA.

Update

Over the past 9 months, Lawrence has continued to struggle with physical health issues - chronic knee, back and elbow pain from deterioration in joints. He had a second right knee replacement in December 2024 followed by rehabilitation at Matilda Nepean, with good effect. He has also been advised that he will need a right hip replacement and has been recommended to proceed with that, however I have asked Lawrence to check with his orthopaedic surgeon about timing to allow for recovery from his right knee replacement. Lawrence’s orthopaedic surgeon has indicated that he may need to consider retirement in the near future, which has caused further anxiety because of ongoing financial stressors.

Lawrence’s mood is better when occupied and being productive. He has just returned to doing a few hours work per week and reported a significant improvement in mood. He is adhering to instructions from his medical team with regards to returning to work in a way that supports his recovery from surgery. Lawrence considered that being able to contribute again to ease the burden of financial stress was positive for him. He continues to wait for the outcome of his work cover claim, which is another cause of frustration. He has started exploring education opportunities for retraining, including a TAFE course for mechanical work.

Other aspects of his life are positive. His grandchildren bring him a lot of enjoyment and the relationship with his parents has improved. He has had a holiday with Esther and a recent trip away with friends which he enjoyed.

Overall, Lawrence’s mood has been up and down over the past 9 months. Deterioration in mood is usually triggered by ongoing financial stressors or a relationship issue with his extended family. When low in mood, Lawrence sleeps a lot more during the day and has difficulty getting out of bed. He also reports difficulty sleeping at night due to rumination of negative thoughts. Despite low mood at times, Lawrence has not had acute suicidal ideation with intent over this period. At the time of his review on the 2nd of April, he was bright and reactive in presentation and his mood was stable.

Assessment

Currently stable in mood, despite financial stressors and physical health challenges.

Plan

During the session, I contacted the WHL intake line and they agreed to extend Lawrence’s current plan for a couple of months. We agreed to decrease his sessions to monthly, and if Lawrence continues to be stable in mood, we will close the referral in the second half of the year.

02.05.22 K10 score: 33/50

11.11.22 K10 score: 45/50

03.05.23 K10 score: 21/50

13.12.23 K10 score: 32/50

12.06.24 K10 score: 21/50

19.02.25 K10 score: 30/50

MSE

Appearance – Middle aged man of Maltese descent, dressed in work clothes; good attention to hygiene and grooming.

Behaviour: Comfortable in consultations. Easy rapport. Good eye contact.

Describes mood as “I’m OK; a bit better; still up and down.”

Affect – Brighter; reactive; able to laugh and joke

Content – as stated above.

Thought form: logical; sequential.

Perception: denies alteration in.

Oriented to time, place and person.

Cognition: not formally assessed; no obvious loss of function.

Insight: Understanding patterns associated with negative core beliefs is an ongoing psychotherapeutic piece of work

Judgement: Good. Is aware of emotional challenges and actively taking steps to seek help and manage his emotions. Able to focus on other things and redirect negative thoughts more easily

Formulation

60-year-old male of Maltese descent, with history of anxiety, depression and suicidal ideation in context of multiple psychosocial stressors in background of childhood trauma, currently stable in mood.

Plan

Continue on the MHNIPs plan. It does not need renewing until August 2025, so no action required by you at this time, Dr Nasr.

Regards,

Michelle Hookham