Daniel Okonkwo

Self-referred through his employer’s scheme after his line manager raised concerns. He is clear in the first minute that he is here "to get back to full capacity", and slightly clearer than necessary that this is not about mental health.

Symptoms have built over three years and sharpened over eight months, following a promotion to lead a team of eleven. He wakes at 4am most days, works until late, and describes weekends as "recovery, not rest". He has stopped playing five-a-side, stopped seeing friends, and describes his relationship with his wife as "fine — we’re just both tired".

PHQ-9 at intake: 17. GAD-7: 11. He is surprised by both, and slightly affronted. He has never been in treatment, and no family member ever has either. He came to the UK from Nigeria at nine, with his mother and sister; his father followed two years later and worked two jobs. He describes his childhood as "fine, normal", and adds without prompting that his father "never missed a day of work in twenty-six years".

The pattern

• Cannot delegate; reviews his team’s work himself, at night.
• Describes any error as "unprofessional" and cannot let one go.
• Has not taken more than four consecutive days of leave in eight years.
• Describes rest as something that has to be earned, and has not earned it recently.
• Says he is "letting everyone down" — and, on enquiry, cannot name anyone who has said so.

The cognitive account

Core belief in the worthlessness family: "I am only acceptable when I am producing." Conditional assumption: "If I slow down, I will be found out and everything I have built will be taken." Compensatory strategy: relentless over-work, which produces exhaustion, which produces errors, which confirms the belief. The loop is closed and self-fuelling.

The dynamic account

The same material read relationally: a wish to be valued for himself; an expectation that others will only respond to what he produces; and a response of self that is to produce more and hide the cost. His father’s twenty-six years is not an anecdote — it is the transmitted rule about what a man in this family is for, and Daniel has never questioned it because it was never stated as a rule.

The behavioural account

Almost all reinforcing activity has been extinguished. Football gone, friends gone, sex gone, rest framed as unearned. What remains is negatively reinforced work — it briefly reduces guilt. Behavioural activation is likely to move him faster than any insight.