Psychotherapist Clinical Note - Brainspotting Psychotherapy Session Note
Session Date and Duration: 1 November 2024, 75 minutes
Client Presenting Issue/Theme/Memory/Incident:
Client presented with persistent anxiety and flashbacks related to a specific childhood incident involving a car accident. Expressed feeling 'stuck' with the memory and its accompanying physical tension.
Initial SUDS Rating: 8/10
Somatic Responses Observed:
Client initially presented with shallow breathing, noticeable tension in the shoulders and jaw, and fidgeting hands. During processing, reported a 'pulling' sensation in the chest and later, a release of tension in the diaphragm. Eye movements were rapid and erratic initially, then became smoother.
Brainspotting Frames Utilised:
Utilised a 'Resourcing Brainspot' initially in the upper left visual field to establish a sense of safety, then moved to a 'Focussed Brainspot' in the lower right visual field, which appeared to trigger the core memory. Adjusted the eye position slightly upwards when client reported feeling overwhelmed, then returned to the lower right.
Processing Observations:
Client exhibited strong emotional responses, including tears and shaking, particularly when engaging with the Focussed Brainspot. Reported vivid visual recollections of the incident. Noted a shift from fear to a sense of detachment as the session progressed. Towards the end, there was a visible relaxation of facial muscles and a deepening of breath.
Post-Processing SUDS Rating: 3/10
Client's Meaning Making:
Client expressed a newfound perspective on the incident, stating, "It feels like it happened to me, but it's not happening to me now. I can finally breathe around it." Also noted a connection between the car accident and a general feeling of helplessness that has permeated other areas of their life.
Session Outcome and Client Response:
Client appeared significantly calmer and reported a reduction in overall anxiety. Expressed surprise at the depth of processing and feeling 'lighter'. Left the session with a sense of relief and hope.
Plan for Next Session:
Continue processing the lingering feelings of helplessness identified during this session. Explore how the newfound perspective on the childhood incident can be integrated into current challenges. Client will practice grounding techniques between sessions.
Session Date and Duration: [date and duration] (Date of session and total session duration. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Client Presenting Issue/Theme/Memory/Incident:
[presenting issue] (Specific issue, theme, memory, or incident that the client brought to the session for processing. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Initial SUDS Rating: [initial SUDS] (Client's initial Subjective Units of Disturbance Scale rating from 0–10 for the presenting issue. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Somatic Responses Observed:
[somatic responses] (Physical sensations, body movements, breathing changes, tension, or other somatic manifestations noted during the session. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Brainspotting Frames Utilised:
[frames utilised] (Specific Brainspotting frames or eye positions used during the session, including any changes or adjustments made. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Processing Observations:
[processing observations] (Notable responses, shifts, or changes observed during the Brainspotting process. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Post-Processing SUDS Rating: [post SUDS] (Client's SUDS rating after Brainspotting processing. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Client's Meaning Making:
[meaning making] (Client's insights, understanding, connections, or meaning derived from the Brainspotting experience. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Session Outcome and Client Response:
[session outcome] (Overall client response to the session and any notable outcomes or shifts. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Plan for Next Session:
[next session plan] (Any plans, follow-up items, or areas to explore in future sessions. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)