Session Note Example

    Topics/Issues Discussed
    • Client and counsellor reviewed updates in clients life since previous therapy session.

    • 39 weeks pregnant, has random contractions.

    • Son has COVID -  really sick; lots of anxiety around that

    • Client reports pitying herself

     

    Themes & Impressions
    • Sickness Anxiety - gets anxiety when family members are ill

    • Psychological Rigidity

    • Lack of responding to body ; never allowed herself to just listen to bodies needs.; including hunger

    • Dissociative state - has lived the most of her life in a dissociative state, not fully connected to self.

    • Numbness

     

    Interventions
    • Counsellor provided support and validation throughout.

    • Counsellor obtained ongoing consent to proceed with therapeutic interventions.

    • Socratic questioning used to challenge idea of pitying herself. Validation provided around pitying herself.

    • explored practical ways to listen to body; hunger cues, body  check ins, breathwork.

    • explored function of client ignoring her body - both good and bad.

    • connected experiences of anxiety to polyvagal theory

    • psychoeducation provided on dissociation

     

    Plan & Homework
    • Sessions to continue

    • listen to body - food cues & check ins.

     

    Treatment Plan/Therapy Direction
    • Sessions & Treatment Plan To Continue

    • Therapist to incorporate polyvagal theory to further explore dissociative tendencies

    • Continue ACT for values work, CBT for anxiety management.

     

    Case Conceptualization/Thoughts for Future Sessions
    • Dissociation techniques