SIMPLE Note Example: Abandonment Trauma

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

The session was 60 minutes and held in-office. Client appeared anxious and reported significant difficulty in her relationship, stating, "Every time he doesn't text me back right away, I just panic." Client described intense fear of abandonment triggered by her partner not responding immediately, seeming distracted, or needing space. She acknowledged that these fears feel irrational but lead to behaviors that push her partner away, exacerbating the fear. Client connected these patterns to abandonment trauma, sharing that her father left when she was very young and she experienced past relationships where people disappeared without explanation. She expressed that this has left her with a persistent belief that people leave and a heightened nervous system response to perceived signs of withdrawal. Therapist introduced emotional regulation strategies, including grounding with the 5-4-3-2-1 technique, self-soothing methods such as using a blanket, listening to calming music, or contacting a safe friend, and reality-testing to assess whether fears are based on present circumstances or past experiences. Therapist also discussed secure attachment strategies, encouraging client to communicate her needs calmly rather than reacting from fear. Client was assigned homework to practice grounding, self-soothing, and reality-testing when abandonment fears arise. The next session is scheduled for next week to review progress.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over, and then Quill would generate a note similar to the one above.

Today's session was 60 minutes, in-office. Vanessa came in looking anxious and said she's been having a really hard time in her relationship. She said quote 'Every time he doesn't text me back right away, I just panic' unquote. She described how even small things, like her partner not responding immediately, or seeming distracted, or needing space, trigger this intense fear that he's going to leave. She said she knows it's not rational, but in the moment it feels so real, and she ends up acting in ways that push him away, which makes the fear worse.

We talked about abandonment trauma and where these patterns might be coming from. She opened up about how her dad left when she was really young, and then later she had a couple of relationships where people just disappeared without explanation. She said she just learned that people leave, and she's always waiting for it to happen again. That wound is still really active, and her nervous system is on high alert for any sign that someone's pulling away.

We worked on some emotional regulation strategies she can use when that panic hits. First, grounding, I taught her the 5-4-3-2-1 technique to help bring her back to the present moment instead of getting lost in the fear. Second, self-soothing, we talked about what she can do to comfort herself in those moments, like wrapping herself in a blanket, listening to calming music, or calling a friend who's safe. Third, reality-testing, asking herself whether the fear is based on what's happening right now or what happened before. We also talked about secure attachment strategies, like communicating her needs to her partner in a calm way instead of reacting from the panic. Her homework is to practice grounding and self-soothing this week when the abandonment fear comes up, and to try reality-testing before she reacts. We'll meet again next week to see how it went.

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More About SIMPLE Notes:

From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about SIMPLE notes.