Treatment Plan Update — Thompson, Aisha M.

Treatment Plan Finalized Risk: Low-Moderate

Summary

Updated treatment plan following 8 sessions of EMDR-based trauma therapy. Client demonstrates consistent progress: nightmare cessation, improved workplace functioning, emerging somatic regulation skills. Hypervigilance remains primary target.

Treatment History

8 sessions completed. EMDR protocol initiated at session 3. Three successful processing sessions targeting index trauma.

Progress Toward Goals

Goal 1 (Reduce nightmares): ACHIEVED — first full nightmare-free week. Goal 2 (Improve workplace functioning): IN PROGRESS — desk relocation, manager disclosure, reduced avoidance. Goal 3 (Develop regulation skills): IN PROGRESS — 4-7-8 breathing, yoga initiated, grounding techniques in use.

Updated Goals

Goal 1: Reduce hypervigilance (PCL-5 hyperarousal subscale from 14 to <8). Goal 2: Tolerate triggering stimuli without freeze response. Goal 3: Expand social activities to pre-trauma levels.

Clinical Impressions

Ms. Thompson has made substantial progress since initiating treatment. The elimination of trauma-related nightmares after the first phase of EMDR processing is consistent with successful desensitization of the primary traumatic memory. Her willingness to engage in increasingly challenging situations (workplace self-advocacy, yoga in triggering environment) demonstrates strong therapeutic alliance and internal motivation. The persistent hypervigilance, while expected at this stage, indicates that autonomic nervous system dysregulation has not yet fully resolved. This is the appropriate next treatment target.

Recommendations

Phase 2 Treatment Goals (next 8-12 sessions): 1. Continue EMDR processing — target workplace-specific triggers (door slamming, sudden noises) 2. Introduce somatic experiencing techniques for hypervigilance 3. Maintain yoga as adjunctive somatic regulation 4. Graduated exposure: increase tolerance for triggering environmental stimuli 5. PCL-5 reassessment at session 12 6. Consider group therapy referral for peer support when ready

Report Details

Report Type: Treatment Plan
Status: Finalized
Generated: Feb 17, 2026 at 6:29 AM
Signed By: Dr. Sarah Mitchell, Psy.D.
Signed At: Feb 9, 2026 at 4:00 PM

Diagnoses (DSM-5)

F43.10 PRIMARY

Post-Traumatic Stress Disorder

Risk Assessment

2/5

Low-Moderate

Risk Level

Risk Factors

Hypervigilance affecting daily functioning, avoidance patterns

Source Session

Aisha M. Thompson

Feb 8, 2026 — 50 min

AMT-2026-0036

AI Analysis Confidence

Diagnostic Accuracy 92%

Treatment Relevance 88%

Risk Assessment 85%

Documentation Quality 95%