Example EMDR Note

SUBJECTIVE

Presentation

Chief Complaint: Client reports ongoing issues with anxiety and fear related to a past traumatic event in which he was attacked and mugged at knifepoint by a group of teenagers.
- Quote (Chief Complaint): "Well, it’s that time I was attacked in the street and mugged by a group of teenagers."
Impairments And Challenges: Client states that this traumatic memory continues to negatively impact him, causing feelings of terror, powerlessness and fear whenever he recalls the event. This suggests impairments in his overall emotional functioning and sense of safety.
- Quote (Impairments And Challenges): "It feels very true."

Psychological Factors:

Symptom 1:
- Symptom Description: Client experiences recurrent and distressing recollections of the traumatic event in the form of vivid sensory memories and imagery.
- Onset: Approximately 2 years ago when mugging occurred.
- Frequency: Daily
- Intensity: Severe, rating of 8/10
- Duration: Ongoing for approximately 2 years
- Quote (Symptom): "I can see a knife, I can see it glinting. One of them’s got a knife, and it’s a really dangerous situation."
Image Details: Client reported visual image of assailant holding a knife as the most disturbing aspect of the memory. Other sensory details include hearing the attackers shouting and sensing feelings of terror.
Negative Cognition: "I'm powerless."
Positive Cognition: "I can handle myself."
Emotional Processing: Client initially reported feeling "terrified" and "really scary" when recalling the image. After processing, reported feeling "a big relief" and reduced distress.

Biological Factors:

Body Sensations: Client reported feeling distress physically in his chest area when recalling the traumatic imagery.

OBJECTIVE

Clinical Assessment:

Interventions

Therapeutic Approach Or Modality: Eye movement desensitization and reprocessing (EMDR) therapy to process the traumatic memory.
Therapeutic Interventions:
- Bilateral stimulation (eye movements) while recalling the traumatic memory and associated thoughts/images/emotions.
- Changing the negative cognition to a positive cognition.
- Reviewing and reprocessing the memory from different perspectives.
Rationale: EMDR an evidence-based approach aimed to reduce disturbing emotions and beliefs tied to the traumatic memory in order to help the client feel safer and more in control.

ASSESSMENT

Progress And Response:

Response To Treatment: Client demonstrated good engagement in reprocessing his traumatic memory and reported reduced SUDs, increased validity of positive cognition, and relief by end of session.
Specific Examples Or Instances: Reported SUDs dropped from 8 to 0 after processing. Validity of cognition rose from 2 to 7.
- Quote (Progress): "It’s completely different now. I really think you know I did the right thing there. That was the way to handle it."
Processing Response: Client stayed connected to memory and bilateral eye movements, reporting new insights, perspectives and memory changes. Showed some reluctance initially but therapist guided through blocks.
Reprocessing Effects: After completing reprocessing, client reported decreased disturbance (SUDs dropped from 8 to 0), increased belief in positive cognition (ratings rose from 2 to 7), and overall relief. Stated "It's a big relief, it's completely different now." These are self-reported effects.

PLAN

Follow Up Actions And Plans:

Homework: Client instructed to keep a diary of any new insights, thoughts or memories that arise in relation to the processed trauma. These can be targeted in future sessions as needed.
Plan For Future Session: Continue trauma processing in future sessions, targeting any new elements that arise as homework. Eventual goals are to reduce PTSD symptoms and increase emotional functioning.
Plans For Continued Treatment: Next session scheduled for client's regular weekly time. Will continue with weekly trauma processing sessions as part of ongoing PTSD treatment plan.
Coordination Of Care: No coordination of care indicated at this time.