Presenting concern: Patient's primary care provider has recommended he try therapy.
Duration of session: Approximately five hours, of which the presenting concern occupied the first ninety seconds.
Interval history
Patient states the concern immediately and without prompting. This represents a marked improvement over the prior session and I recorded it as such. He did not return to it.
He reports no current pharmacotherapy. A previously prescribed anxiolytic was discontinued several months ago; he characterizes the class as slow-acting and describes its anticipated endpoint as "an unmotivated vegetable." He further reports that his concerns regarding attention were assessed and attributed to depression, and that an antidepressant was offered on that basis. Additional recommendations he has received include church and a change of career.
He declined to elaborate on any of this and moved to the subject of file architecture.
Content of session
The patient has spent the interval constructing a governing-document system for a psychiatric practice that does not exist.
Seven files, one concern each. He distinguishes rules that may never change from facts not yet established, and keeps the latter deliberately empty — committing to detail in advance, he says, is how a fiction paints itself into a corner. He has tabulated which of his professional axioms must be reversed for this work, so that the reversals are recorded rather than drifted into.
One provision merits recording. Having written a set of guidelines and then loosened them, he found he could not predict how a later reader would take the loosening. Rather than rewrite it, he required that every departure be logged with its reasoning. He described this as what he does with instrument error: do not trust the stated tolerance, measure the residual, fence off whatever cannot be permitted to drift.
The documentation runs to approximately eight thousand words. The practice has one published note.
Mental status
Alert. Oriented. Working. At one point the patient rejected a phrase in his own drafting standard on the grounds that it would apply equally to any capable, anxious person and was therefore insufficiently specific. He objected in particular to the word "smart," which he identified as flattering, generic, and liftable onto anyone. I have recorded the objection and no rebuttal.
The work was conducted between approximately 10:00 p.m. and 3:00 a.m. When the hour was noted, the patient observed that the night was still young.
Course of session
Patient concluded with "it is what it is." The phrasing varies between sessions. The function does not.
Assessment
Plan
The referral has, in a sense, been completed. I have recorded it as fulfilled.
Continue current course. Patient will likely return having formalized something adjacent to the problem, and will state the presenting concern promptly and then leave it where it lies.