Psychologist EMDR Consultation Initial Clinical Notes Template

EMDR Consultation Clinical Notes

Presenting Complaint:

The patient, referred to as “Jane,” presents with ongoing distress related to past trauma. She reports frequent intrusive memories of a car accident that occurred two years ago, which led to significant emotional distress and physical injuries. Jane seeks EMDR therapy to reduce the intensity of these traumatic memories and alleviate symptoms of anxiety, hypervigilance, and insomnia that have persisted since the incident.

History of Presenting Condition:

• Onset & Duration:

Jane’s trauma symptoms began immediately after the car accident, which occurred two years ago. She recalls experiencing a sense of panic during the event, which was compounded by physical injuries and prolonged hospital stays. Over the past two years, Jane has struggled with flashbacks, nightmares, and a heightened startle response. Her anxiety worsens in situations that remind her of the accident, including when she is in or near cars, or when driving.

• Previous Treatments:

Jane has been seeing a therapist for cognitive-behavioral therapy (CBT) since shortly after the accident. While she experienced some relief from her anxiety and insomnia, she continues to struggle with intrusive memories and emotional numbing. Medications, including SSRIs (Fluoxetine 20 mg daily), were prescribed by her psychiatrist, but she reports limited effectiveness for managing the intensity of the traumatic memories.

• Relevant Medical and Psychiatric History:

Jane has no history of significant medical issues beyond the injuries sustained in the accident, which included a mild concussion and soft tissue damage. She has a history of generalized anxiety disorder, which worsened after the trauma. There is no significant history of depression or other psychiatric disorders in her background.

• Impact on Personal and Social Life:

Jane reports that the traumatic memories are interfering with her work and personal relationships. She avoids social events and driving, leading to feelings of isolation and a decreased quality of life. She also experiences difficulty concentrating and finds it challenging to focus on work tasks due to intrusive thoughts about the accident.

EMDR Session Details:

Phase 1: History and Target Memory Identification

• Jane was able to identify the traumatic car accident as the primary issue she wishes to address in EMDR therapy. She shared vivid details of the accident, describing the physical sensations she experienced during the event (e.g., rapid heartbeat, tightness in the chest, feeling trapped) and the emotional impact it has had on her since.

• Jane was encouraged to identify other memories that are linked to the accident, and she acknowledged recurring thoughts about the event, especially during moments of high stress.

Phase 2: Assessment of Readiness and Coping Strategies

• Jane was assessed for her readiness for EMDR, and we discussed the therapeutic process in detail to ensure her comfort.

• We established a “safe place” exercise, where Jane created a mental image of a peaceful beach setting. She was able to access this safe place with ease and reported a sense of calm when visualizing it.

• Several coping strategies were reinforced, including deep breathing and grounding techniques.

Phase 3: Target Memory Assessment

• Target Image:

The distressing memory identified by Jane is a vivid image of her vehicle spinning out of control before the crash.

• Negative Cognition (NC):

Jane expressed a belief of “I am not safe” when thinking about the accident.

• Positive Cognition (PC):

Jane wishes to replace this belief with “I am safe now.”

• VOC Rating:

Jane rated her belief in the positive cognition at 3/7, feeling moderately unsure of her safety despite the passage of time.

• Emotion:

Jane identified the primary emotion linked to the memory as fear.

• SUDS Rating:

Jane rated her current distress level at 8/10 when recalling the memory of the accident.

• Body Sensation:

Jane reported tension in her shoulders and a tightness in her chest when recalling the accident.

Phases 4-6: Desensitization Process

• SUDS Changes:

Throughout the desensitization process, Jane’s SUDS rating began at 8/10 but gradually decreased to 5/10 after several rounds of bilateral stimulation.

• VOC Adjustments:

By the end of the session, Jane reported an increase in belief in the positive cognition “I am safe now,” with a VOC rating of 5/7.

• Insights:

Jane reported gaining a sense of emotional distance from the memory, feeling less overwhelmed by the emotions and physical sensations tied to the trauma. She also noticed a decrease in the vividness of the target image.

Phase 7: Closure Techniques

• To close the session, Jane was reminded of her safe place and instructed to focus on positive, calming thoughts. She was encouraged to use the safe place imagery during moments of distress outside of therapy.

Phase 8: Future Session Planning

• For the next session, we will continue processing the trauma related to the car accident, focusing on reducing Jane’s SUDS rating and strengthening her positive cognition of safety. We will also explore other potential traumatic memories linked to the incident that may require further attention.

Aggravating and Easing Factors:

• Aggravating Factors:

Driving or being in a car, especially when there are reminders of the accident (e.g., wet roads, fast driving). Stressful work events and situations that trigger feelings of vulnerability or lack of control.

• Easing Factors:

Practicing safe place imagery and grounding techniques; physical activity such as walking; talking to supportive family members.

Medications:

• Fluoxetine (20 mg daily): As mentioned, Jane has been on this medication for generalized anxiety disorder, but she reports it has not significantly reduced her trauma-related distress.

Client Concerns:

• Jane expressed concerns about her ability to fully recover from the trauma. She is also anxious about how the therapy process might unfold and whether she will be able to let go of the fear and hypervigilance that have defined her daily life since the accident.

Goals for Therapy:

1. Reduce the intensity of traumatic memories related to the car accident.

2. Decrease symptoms of hypervigilance, anxiety, and intrusive thoughts.

3. Increase belief in personal safety and self-efficacy in coping with distressing thoughts.

4. Improve overall quality of life by re-engaging in previously avoided activities, such as driving and socializing.

Next Appointment:

• Date: November 28, 2024

• Focus: Continue processing the target memory and work on reducing the SUDS rating. Explore any other related memories or triggers that may need attention.

Additional Notes:

• Jane was cooperative throughout the session and engaged well with the EMDR process. She expressed a desire to continue working through the trauma in subsequent sessions. She was encouraged to track any changes in her symptoms or distress levels between sessions.

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