SOAP 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.

Subjective:
Client reported feeling anxious and described significant difficulties in her relationship. She stated, "Every time he doesn't text me back right away, I just panic." Client shared that small behaviors from her partner, such as delayed responses, distraction, or needing space, trigger intense fear of abandonment. She acknowledged that these fears feel irrational but lead to behaviors that push her partner away, exacerbating her anxiety. Client discussed past experiences of abandonment, including her father leaving when she was young and previous relationships where partners disappeared without explanation. She expressed that these experiences have left her feeling hypervigilant to signs of rejection.

Objective:
Session duration was 60 minutes, conducted in-office. Client appeared anxious upon arrival. Therapist taught the 5-4-3-2-1 grounding technique, discussed self-soothing strategies such as using a blanket, calming music, or contacting a safe friend, and guided the client in reality-testing to differentiate current fears from past experiences. Secure attachment strategies, including calm communication of needs to her partner, were also explored.

Assessment:
Client continues to experience significant anxiety and fear of abandonment, which aligns with her history of trauma. She demonstrated insight into the origins of her patterns and engaged actively in learning emotional regulation and attachment strategies. Client appears motivated to address these challenges and practice the techniques discussed.

Plan:
Client was assigned homework to practice grounding and self-soothing techniques when feelings of abandonment arise and to engage in reality-testing before reacting. The next session is scheduled for next week, in-office, to review her progress and continue working on emotional regulation and attachment strategies.

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 SOAP 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 SOAP notes.