During today's 45-minute office session, the client presented with visible anxiety, discussing recent intrusive memories of a past medical procedure. The client stated, 'I just shut down whenever I think about it,' and reported physical symptoms such as tension, accelerated heart rate, and shortness of breath. The therapist explored the concept of medical trauma and its potential impact, which can be as significant as other types of trauma. A grounding technique involving the five senses was introduced and practiced to assist the client in staying present during episodes of overwhelming memories. The client was assigned homework to apply this technique when experiencing intrusive thoughts. The session concluded with the client appearing somewhat relieved, having acquired a practical tool to manage their symptoms. The therapist and client agreed to reconvene next week to evaluate the effectiveness of the grounding technique and consider further therapeutic strategies.
SIMPLE Note Example
Trauma from Medical Procedures
Client is processing trauma related to past medical procedures.
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Client Session Summary:
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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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