Presenting Problem(s):
- Provide a brief summary of trauma-related symptoms and issues discussed
- Describe what aspect of the trauma-focused cognitive behavioural therapy treatment phase the client is currently in (e.g., Psychoeducation, Relaxation, Affect Modulation, Cognitive Processing, Trauma Narrative, Cognitive Restructuring, In Vivo Exposure, Enhancing Safety)
- Summarise other concerns or difficulties discussed
- Highlight any relevant updates to symptoms, behaviours, or situations since the previous session
- Detail the client’s current emotional state, and indicate the type and results of any assessments used by the therapist in session
- Detail any relevant life events or current circumstances contributing to the client’s presentation
Session Content:
- Provide a summary of the session
- Include information related to the client’s experience of trauma, how their daily functioning is impacted, and their efforts at managing their emotional state
- Include any review of homework and the client’s progress with tasks from the previous session, including barriers and successes
- Include key topics discussed, core issues explored and how they relate to the client’s presentation and treatment goals
CBT Formulation:
- Situation: Describe the triggering circumstances or event that started a cycle
- Thoughts: Describe the automatic negative thoughts that occur in response to the situation
- Emotions: Describe the feelings that are generated by the automatic negative thoughts
- Physical Sensations: Describe the physiological reactions that occur in response to these thoughts and emotions, such as heart palpitations, stomach upset, tension, fatigue
- Behaviours: Describe the actions or reactions that result from these thoughts, emotions, and physical sensations, as well as any feedback loops
Unhelpful Thinking Style:
- Describe any thoughts associated with cognitive distortions. Note if the therapist identified or challenged these thoughts
Core Beliefs:
- Describe any core beliefs, schemas or foundational beliefs, and any associated experiences
Interventions Used:
- Detail specific trauma-focused cognitive behavioural therapy therapeutic interventions used by the therapist in the session (e.g., psychoeducation, cognitive restructuring, affect regulation, exposure, processing the trauma narrative, and any other trauma-focused cognitive behavioural therapy intervention)
- Summarise how these interventions were received by the client and any feedback from the client, including level of understanding of the interventions shown
- Detail any notable shifts in thinking or behaviour expressed by the client
Key Insights and Client Responses:
- Describe the client’s emotional and behavioural responses; including the client’s affect, engagement, level of distress, or resistance during the session
- Describe any cognitive shifts observed in the client
- Describe the client’s ability to use learned coping skills or techniques outside of therapy
- Highlight any other important themes that emerged during the session
Therapeutic Relationship:
- Briefly comment on the therapeutic alliance or dynamics observed in the session
- Note any areas where rapport was strengthened or challenges arose
Homework or Action Plan:
- Describe homework or tasks assigned to the client, including rationale and expected outcomes
- Note any feedback or concerns from the client about the homework
Risk Assessment:
- Summarise any risk factors, such as self-harm or suicidal ideation
- List protective factors that mitigate the risk, and any action plans if risk is present
Trauma-Informed Summary:
- Provide a summary of the client’s trauma symptoms, functional impairment, and overall progress
Next Steps:
- Outline the preliminary agenda or goals for the next session
- Provide the time, day and date of any future session agreed upon
Presenting Problem(s):
- Mary is in the Cognitive Processing phase of trauma-focused CBT following a motor vehicle accident six months ago. She reported decreased intrusive thoughts from daily to 3-4 times weekly and improved sleep with relaxation techniques.
- SUDS rating for accident-related distress decreased from 8/10 to 6/10 since last session.
- Continues avoiding highway driving and experiences significant anxiety as a passenger.
Session Content:
- Session explored Mary’s driving avoidance and its impact on independence, particularly her inability to drive to work independently.
- Homework review showed successful completion of relaxation exercises but difficulty with thought monitoring worksheets.
- Discussed relationship strain with partner who has become primary driver for all activities.
- Explored Mary’s guilt about the accident and beliefs about personal responsibility despite evidence of weather-related contributing factors.
CBT Formulation:
- Situation: Needing to travel by car, particularly on busy roads or in weather conditions similar to the accident
- Thoughts: “I’m going to crash again,” “I can’t handle driving safely,” “The accident was my fault”
- Emotions: Intense fear, guilt, helplessness
- Physical Sensations: Rapid heartbeat, sweating, muscle tension, nausea
- Behaviours: Complete driving avoidance, reliance on others for transport, cancelling activities requiring car travel
Unhelpful Thinking Style:
- Catastrophising: “If I drive again, I’ll definitely have another accident.”
- Self-blame: “The accident was completely my fault, I should have been more careful.”
- All-or-nothing thinking: “I’m either a safe driver or I’m dangerous”
Core Beliefs:
- “I am responsible for bad things that happen to me.”
- “The world is dangerous and I have no control.”
- “I can’t trust myself to make good decisions.”
Interventions Used:
- Cognitive restructuring to challenge self-blame using evidence-for-and-against worksheets, helping Mary recognise weather conditions as contributing factors. Psychoeducation about trauma’s impact on safety perception and threat assessment.
- Introduction of graded exposure hierarchy for driving activities, beginning with sitting in stationary car. Mary demonstrated good understanding and engaged actively with evidence examination.
Key Insights and Client Responses:
- Mary showed moderate distress discussing accident details but remained engaged throughout. Notable cognitive shift occurred when she recognised weather conditions contributed significantly to the accident.
- Expressed resistance to resuming driving but acknowledged current avoidance limits her independence. Successfully demonstrated breathing techniques during moments of increased session distress.
Therapeutic Relationship:
- Strong therapeutic alliance maintained with Mary expressing trust in the treatment process. She appreciated the collaborative approach to developing the exposure hierarchy and felt supported rather than pressured.
Homework or Action Plan:
- Complete daily thought records focusing on driving-related anxious thoughts, examining evidence for catastrophic predictions.
- Continue progressive muscle relaxation twice daily and begin exposure hierarchy by sitting in stationary car for 5 minutes daily.
- Mary acknowledged apprehension about car exposure component.
Risk Assessment:
- No current suicidal ideation or self-harm behaviours reported.
- Strong protective factors include supportive partner relationship, stable employment, and consistent treatment engagement.
Trauma-Informed Summary:
Mary experiences moderate re-experiencing through intrusive thoughts, though frequency has decreased with treatment. Avoidance symptoms remain most functionally impairing, with complete driving avoidance severely restricting independence and creating relationship strain. Hyperarousal manifests primarily in car-related contexts with significant physiological activation. Sleep disturbances have substantially improved with relaxation techniques. She shows excellent progress in cognitive processing with increased ability to examine evidence objectively. Further exposure-based interventions are needed to address avoidance behaviours and restore driving capacity.
Next Steps:
- Review exposure homework experience and progress to next step in driving hierarchy involving starting car engine while stationary. Continue cognitive restructuring work on beliefs about personal responsibility and control.
- Next appointment scheduled for Wednesday, 12th June 2025 at 10:00 AM.
