Counselor's Clinical Note
Date: 1 November 2024
Presenting Issue or Memory
Ms. Johnson presented with feelings of anxiety and sadness related to a past traumatic event. She reported difficulty sleeping, intrusive thoughts, and avoidance behaviours. She expressed feelings of self-blame and worthlessness, particularly in relation to the traumatic incident. She also described feeling overwhelmed by her emotions and struggling to cope with daily stressors. She has been experiencing flashbacks and nightmares related to the event, which have significantly impacted her daily functioning. She also reported feeling isolated and withdrawn from social activities.
Image
Ms. Johnson described a positive image of herself as a child, playing in a park with her family. She recalled the sensory details of the warm sun, the smell of freshly cut grass, and the sound of laughter. The positive cognition associated with this image was a sense of safety, love, and belonging.
Negative Cognition
Ms. Johnson identified several negative cognitions, including "I am not safe," "I am worthless," and "It's all my fault." She expressed a strong belief in these statements, particularly in moments of distress. She also stated, "I can't trust anyone," and "I'm going to be alone forever."
Positive Cognition
During the session, positive cognitions were introduced, such as "I am safe now," "I am worthy of love," and "I am resilient." Ms. Johnson initially struggled to accept these cognitions but gradually began to acknowledge their validity. She responded positively to the idea of self-compassion and the possibility of healing.
Validity of Cognition
Ms. Johnson rated the validity of her negative cognitions as high initially, but as the session progressed, she began to question their accuracy. She rated the validity of the positive cognitions as moderate, acknowledging their potential but still struggling to fully embrace them. She rated the negative cognition "I am not safe" as a 9/10 at the start of the session, and a 5/10 at the end. She rated the positive cognition "I am safe now" as a 3/10 at the start of the session, and a 7/10 at the end.
Emotions
Ms. Johnson reported experiencing intense feelings of fear, sadness, and anger. She also described feeling shame and guilt related to the traumatic event. Therapeutic techniques such as grounding exercises and deep breathing were used to help her manage these emotions. She reported feeling a sense of calm after practicing these techniques.
SUDs
Before the session, Ms. Johnson's Subjective Units of Distress (SUD) level was 8/10. During the session, she visualized the traumatic event, which initially increased her distress to 9/10. After processing the memory and introducing positive cognitions, her SUD level decreased to 4/10.
Location of Body Sensation
Ms. Johnson reported feeling a tightness in her chest and a knot in her stomach when recalling the traumatic event. She also experienced a racing heart and shallow breathing. These physical sensations were most intense during the visualization of the traumatic memory.
Desensitization
The desensitization process involved repeatedly visualizing the traumatic event while focusing on the positive cognitions. The therapist used bilateral stimulation (eye movements) to facilitate processing. Ms. Johnson's responses included initial distress, followed by a gradual decrease in anxiety and physical sensations. Her SUD level decreased from 9/10 to 4/10 during the desensitization phase. She reported feeling a sense of relief and empowerment at the end of the session.
Presenting Issue or Memory
[describe the client's current symptoms, coping patterns, and any specific issues discussed during the session, including any feelings of self-criticism or negative thoughts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Image
[describe any positive imagery recounted by the client, including sensory details and the positive cognition associated with the image] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Negative Cognition
[document the client's negative beliefs and statements, particularly those related to self-criticism and feelings of helplessness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Positive Cognition
[describe any positive cognitions introduced during the session and the client's response to these cognitions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Validity of Cognition
[evaluate the client's negative and positive cognitions, including the client's acknowledgment of these beliefs and any ratings of believability or validity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Emotions
[report the client's emotions, particularly those associated with specific triggers or situations, and any therapeutic techniques used to address these emotions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
SUDs
[document the client's Subjective Units of Distress (SUD) levels before and after the session, including any specific triggers visualized and the changes in distress levels] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Location of Body Sensation
[describe any physical sensations reported by the client, including the location, nature, and context of these sensations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Desensitization
[detail the desensitization process during the session, including any techniques used, the client's responses, and changes in distress levels or physical sensations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
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