Session Transcript
7 exchangesMarcus, welcome back. How has this week been for you?
Tough. The nightmares are getting worse. Five nights this week.
That's hard. I want to normalize that a bit — it's common for nightmares to increase when we're actively processing trauma material. It usually means the processing is happening, even though it doesn't feel good.
I did finish the trauma account. And I tried the worksheet, but I couldn't get through all of it.
You got partway through. Tell me about that — where did it get hard?
Question 4, about evidence. When I tried to think about evidence for 'I should have prevented it,' I just... my chest got tight. I took a break and came back but I still couldn't do the last two questions.
The fact that you came back to it after the break shows real commitment. Let's work through those remaining questions together today.
Subjective
Patient reports increased nightmare frequency (5/7 nights, up from 4/7 last week). Completed trauma account with added sensory details. Attempted challenging questions worksheet but was unable to complete questions 6-7 due to emotional activation. Reports emerging capacity for self-directed cognitive challenging outside of session ('I can say that to other people but not to myself').
Objective
Session 6 of 12-session CPT protocol. Patient visibly distressed when discussing nightmare content but maintained engagement. Affect dysregulated briefly at session midpoint during in-session worksheet completion, recovered with grounding. Homework completion: trauma account complete, challenging questions worksheet partial (5/7 questions), nightmare tracking complete.
Assessment
Active trauma processing phase proceeding as expected. Nightmare increase is consistent with CPT trajectory at session 6. Self-blame stuck point ('I should have been able to prevent it') remains primary target. Patient's journal entry suggests emerging perspective-taking capacity — a positive prognostic indicator for stuck point resolution. Emotional tolerance for trauma material is building but requires continued scaffolding.
Plan
- ▸Complete remaining challenging questions for self-blame stuck point in session
- ▸Introduce patterns of problematic thinking worksheet
- ▸Monitor nightmare frequency — if above baseline at session 8, consider imagery rehearsal therapy referral
- ▸Continue trauma account (next draft: focus on meaning-making)
- ▸Reinforce emerging self-directed cognitive challenging