EMDR Note

Client Information: - Client Name: John Doe - Provider Name: Dr. Emily Smith - Date of Service: 1 November 2024 - Session Duration: 60 minutes SUBJECTIVE: Presentation: - Chief Complaint: Client reports ongoing issues with anxiety and fear related to a past traumatic event in which they were involved in a car accident. - Impairments and Challenges: The client describes feelings of terror, powerlessness, and fear when recalling the event, impacting their ability to drive or be a passenger in a vehicle. Psychological Factors: - Symptom Description: Recurrent and distressing recollections of the traumatic event in the form of vivid sensory memories and imagery. - Image Details: Client reported visual image of the car crash as the most disturbing aspect of the memory. - Negative Cognition: "I'm not safe." - Positive Cognition: "I can protect myself." - Emotional Processing: Initially felt 'terrified,' but after processing, reported feeling 'relief.' Biological Factors: - Body Sensations: Client reported chest tightness during memory recall. OBJECTIVE: Clinical Assessment: - Assessment Tool: Clinical Interview. - Results: Client exhibits symptoms consistent with PTSD. - Status: Ongoing assessment. - Validity of Cognition Rating: Initial: 2/7; Final: 6/7 - SUDs Rating: Initial: 8/10; Final: 1/10 Interventions: - Therapeutic Approach or Modality: Eye Movement Desensitization and Reprocessing (EMDR). - Therapeutic Interventions: Bilateral stimulation and cognitive restructuring. - Rationale: To reduce disturbing emotions and beliefs tied to the traumatic memory and help the client feel safer and more in control. ASSESSMENT: Progress and Response: - Response to Treatment: Client reported SUDs dropping from 8 to 1 and validity of cognition rising from 2 to 6. - Quote (Progress): "I feel like I can finally breathe again." - Processing Response: Client was engaged during processing and reported a shift in memory perception. - Reprocessing Effects: Client reported relief, decreased disturbance, and increased belief in positive cognition. PLAN: Follow-Up Actions and Plans: - Homework: Client instructed to keep a diary of new insights or memories arising after session. - Plan for Future Session: Continue trauma processing, targeting new elements identified in homework. - Plans for Continued Treatment: Continue weekly trauma processing sessions to reduce PTSD symptoms and increase emotional functioning. - Coordination of Care: No coordination of care indicated at this time.