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Data:
Client attended a 45-minute session in the therapist's office, presenting with visible anxiety. Client reported an increase in intrusive memories from a past medical procedure, stating 'I just shut down whenever I think about it' and noting physical symptoms such as tension, accelerated heart rate, and difficulty breathing. The session focused on the introduction and practice of a five senses grounding exercise to manage overwhelming feelings associated with these memories.
Assessment:
Client is experiencing symptoms consistent with medical trauma and is beginning to recognize its impact. The grounding technique was well-received and appeared to reduce anxiety levels during the session. Client's engagement with the exercise suggests a willingness to develop coping strategies.
Plan:
Client was assigned the task of utilizing the five senses grounding technique as homework. The therapist and client will reconvene next week to review the effectiveness of the technique and potentially explore deeper emotional responses related to the trauma. The continuation of the current treatment plan will be assessed based on client's progress.
We had a 45-minute office session today, and the client came in looking pretty anxious, talking about how memories from a past medical procedure have been coming up more and more lately. They said quote 'I just shut down whenever I think about it' unquote and described how it’s affecting them physically, too—like they get tense, their heart starts racing, and they feel like they can’t breathe. We talked about how medical trauma can sometimes be just as intense as other types of trauma, even though people don’t always recognize it that way.
We spent some time going over a grounding technique that could help them stay present when those memories come up, because they’ve been feeling pretty overwhelmed. I walked them through the five senses grounding exercise—focusing on what they can see, hear, touch, taste, and smell to bring them back to the present. They seemed to relax a bit once we practiced that. Their homework is to try using that technique whenever they feel those memories creeping up, just to see if it helps them stay grounded. By the end of the session, they seemed a little more at ease, like they finally had something concrete to try. We’ll meet again next week to see how it’s going and maybe start digging into some of the deeper emotional stuff after they’ve had a chance to try out the grounding.
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