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Subjective:
Client attended a 50-minute office session. Client reported noticing that her body reacts to certain topics before her mind does, describing symptoms such as a tight chest, shallow breathing, and shaking hands. She stated, "I don't even have to think about the details, my chest just gets tight and I can't breathe right." Client described a sense of threat in her body even when not consciously thinking about the trauma.
Objective:
Session duration was 50 minutes, held in the office. Client presented with visible tension, including raised shoulders and tightly crossed arms. Guided orienting and grounding interventions were applied, including noticing sensory details in the room, focusing on feet and chair support, and tracking body sensations. Client's shoulders visibly relaxed during the session, and she reported feeling a little less stuck by the end.
Assessment:
Client is making progress in building awareness of body-based trauma responses and increasing her capacity to tolerate these sensations without becoming overwhelmed. Interventions were effective in helping her feel more present and reducing tension.
Plan:
Client will practice orienting and grounding exercises once daily, particularly when noticing body-based cues of threat. The next session is scheduled for next week in the office, where the focus may continue on building her capacity to stay present with sensations safely.
We had a 50-minute office session today. Alicia came in and right away I could see she was holding a lot of tension, shoulders up, arms crossed tight. She said she's been noticing that whenever certain topics come up, even just in passing, her body reacts before her mind does. She said quote 'I don't even have to think about the details, my chest just gets tight and I can't breathe right' unquote. She described this sense of threat that shows up in her body, tight chest, shallow breathing, sometimes her hands start shaking, even when she's not consciously thinking about the trauma.
We talked about how the body holds onto trauma, and how those sensations are the nervous system's way of trying to protect her, even when there's no actual danger in the present. I explained that we don't need to go into the details of what happened, we can work with what's happening right now in her body. We started with some gentle orienting, I asked her to look around the room and notice five things she could see, just to help her nervous system register that she's safe here in this moment. She took a few deep breaths and her shoulders started to drop a little.
Then we did some grounding work. I guided her to notice her feet on the floor, the chair supporting her, and to press her feet down gently and feel that solid contact. We went slow, checking in with her sensations as we went. Whenever she noticed her chest getting tight, we paused and just tracked it, where exactly is it, does it have a shape, does it change when you breathe into it. The goal was just to build her tolerance for those sensations without getting overwhelmed. By the end of the session, she said she felt a little less stuck in it. Her homework is to practice that orienting and grounding exercise once a day, especially if she notices those body-based cues of threat coming up. We'll meet again next week and keep building her capacity to stay present with those sensations safely.
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