Therapy Note Example

Trauma Treatment Without Reliving the Pain

Client worked on trauma healing using a stabilization-first approach, focusing on present triggers and nervous system regulation.

Therapy Progress Notes:

These therapy progress notes were written by Quill based on this specific therapy scenario.

Client Session Summary:

The therapy progress notes listed above were generated based on this summary of a client session. Quill does not record the client session. Hopefully this helps illustrate how Quill works -- a therapist would provide a summary (like this one below) after the session is over, and Quill would then generate a note like one of these examples above.

We had a 50-minute office session today. Nina came in and said she's been wanting to work on her trauma, but she's really scared of having to talk about it in detail. She said quote 'I don't think I can handle going through it all again' unquote. She's been having symptoms, nightmares, flashbacks, hypervigilance, but the idea of retelling the story feels overwhelming, and she's worried it'll make things worse.

I reassured her that trauma healing doesn't have to mean reliving the pain. We can work on the symptoms and help her feel safer in her body without doing intensive trauma narrative work. I explained that we'd use a stabilization-first approach, focusing on what's happening for her now and building up her resources before we ever go near the details. She seemed really relieved to hear that.

We started by identifying her present-day triggers, situations, sounds, smells, or feelings that set off the trauma response. She said crowded places and sudden loud noises are big ones. Then we worked on resourcing, I asked her to think of a place, real or imagined, where she feels completely safe. She described her grandmother's garden, and we spent some time building that image in detail so she could use it as an anchor when she feels triggered. We also did some nervous system regulation work, practicing slow breathing and noticing where she feels calm or neutral in her body, so she can start to build a sense of safety from the inside out.

Her homework is to practice going to her safe place visualization once a day, and to notice her triggers this week without judgment, just tracking them. We'll keep working on stabilization and regulation, and we won't move into trauma processing until she feels ready and resourced enough. She said she feels like she can actually do this now. We'll meet again next week.

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