Case Study 2 — Amara: The Body in the Room

What Amara Carried Home

The sessions ended at different times.

With some clients, Amara walked out of the room and left the session in the room — cognitively present to what had occurred, able to reflect on it with clinical distance, but not carrying the emotional weight in her body. With others, she walked out still holding something.

She had been aware of this for some time. She had attributed it to empathy as a trait — some clinicians absorbed more, some less; she was a high absorber; this was simply who she was.

The chapter on physical health and psychological wellbeing gave her a different vocabulary.

The Somatic Residue

The concept that landed first was psychoneuroimmunology — specifically, the description of empathic engagement as a form of physiological activation.

The chapter didn't use that framing exactly. It described how chronic stress activates the HPA axis, elevates cortisol, increases inflammatory markers, and over time suppresses immune function. But Amara made the connection herself, sitting in the library between class and her afternoon practicum shift: The kind of presence required for clinical work activates the same physiological systems as stress. Sustained, high-quality empathic attunement is not metabolically free.

She had known this in principle — the clinical literature on vicarious traumatization and compassion fatigue was part of her coursework. But she had been thinking about it psychologically (as a risk to her emotional reserves and clinical effectiveness), not physiologically (as something her body was doing in the session, and needed to recover from after).

The chapter's description of allostatic load — the cumulative cost of chronic activation — applied directly. She had been in high-intensity clinical work five days a week for two semesters. She had the post-session breathing practice (one minute after closing the door — the tiny habit she'd built in Chapter 29). She had the decompression walk to the bus. But she had not thought about the physical dimension of what she was doing when she was doing clinical work.

She scheduled a supervision session to talk about it.

The Marcus Conversation

Marcus had been her supervisor for fourteen months. He had a particular quality she'd come to trust: he did not rush toward resolution. He sat with questions.

She described what she had been noticing. "There are some clients where I leave the session and my nervous system is still in the session. Physiologically. Like my heart rate is elevated, or my breathing is shallow, or I notice I've been holding tension in my shoulders that I wasn't consciously tracking. And then I spend the next hour before the next client trying to come back to something baseline."

Marcus: "How long has this been happening?"

"I think it's always been happening. I've only been naming it recently."

"What's the difference between what you're describing and what the vicarious traumatization literature calls compassion fatigue?"

Amara thought about this. "Compassion fatigue is more about the cumulative emotional depletion — losing the ability to care, cynicism, burnout. What I'm describing is more... acute. Within-session and immediately post-session physiological activation that takes time to resolve. Not depletion exactly. More like not having enough recovery built into the structure."

Marcus nodded. "The literature on secondary traumatic stress is relevant. But what you're also describing is a basic occupational physiology reality — the work we do puts us in sustained states of alertness, which have a physiological substrate, which requires genuine recovery time. Not just different cognitive work, but physiological downregulation."

"The chapter I read described something called the social baseline theory — the idea that the nervous system's default state assumes social proximity, and that sustained close contact with people in distress activates the same threat-response systems as more obvious stressors."

"That's plausible," Marcus said. "How are you currently recovering between sessions?"

Amara described the breathing practice. The decompression walk. The scheduling — she tried to leave 30 minutes between her most difficult sessions. Marcus listened. Then: "What does your body look like after the most activating sessions, specifically?"

"Tense. Elevated heart rate. Breathing higher in my chest than usual. Sometimes my jaw is tight and I don't notice until I'm on the bus."

"And your current practices address the cognitive and emotional transition, but what about the physiological one?"

She didn't have an immediate answer.

Movement as Regulation

Amara's apartment was a 25-minute walk from the practicum clinic. She had, until this point, taken the bus in both directions — 12 minutes each way, efficient.

The experiment she designed was simple: walk home after the most activating sessions.

The first time she tried it, after a session with a client who had disclosed a childhood detail that Amara had not expected and that had arrived with physical force — she walked the 25 minutes home and noticed something happening in the middle of it. Her breathing had changed. Around minute 12, she felt her shoulders drop. The physical tension she had been carrying since 3:15 PM was metabolizing into the movement in a way that the bus ride had never permitted.

She began tracking it informally. Days she walked home after activating sessions versus days she bused. The pattern was consistent: the walk changed something that the bus did not. Not the cognitive processing of the session — she could do that on the bus too. The physiological state.

She applied the BDNF mechanism retroactively: the aerobic component of the walk was elevating BDNF, which supported the emotional regulation circuits that the session had taxed. She was running a recovery protocol without having designed it as one.

She told Marcus: "I think the walk home has always been physiological recovery. I just didn't know what I was doing."

"Most good clinical self-care practices were discovered empirically before they were explained mechanistically," Marcus said. "The important thing is that you're now doing them intentionally."

The Client With the Unexplained Fatigue

In the practicum clinic's caseload, Amara was assigned a client in March — a woman in her early 40s who had been referred by her primary care physician for "chronic fatigue with no apparent medical cause."

The physician's note included: normal bloodwork, normal thyroid function, normal sleep study, no sleep apnea. The client had been seen by four specialists. Nothing explained the fatigue. The referral for psychological evaluation was, she had been told by her doctor, essentially "ruling things out."

Amara knew exactly what this felt like for the client before she walked into the first session.

"I know you've been through a lot of evaluations," she said. "I want to start by saying: this isn't about ruling psychology in to explain what medicine couldn't find. It's about understanding your full situation, which medicine doesn't always have time to do."

The client — Andrea — sat back slightly. "Most people say something like 'this might be stress.' They don't say it directly but you can hear it."

"What would you think if they did say it directly?"

"I'd think they were wrong. Or dismissing me."

Amara spent the next session doing a comprehensive history: not just the fatigue, but Andrea's life in the two years preceding the fatigue onset. What emerged:

Andrea's mother had died unexpectedly 26 months ago — Andrea had been the primary caregiver through a four-month illness that had required Andrea to fly home monthly
Andrea had returned to work within one week of her mother's death, "because the project couldn't wait"
She had not taken a vacation in 22 months
She described her current state as "like a computer that's overheated — I shut down unexpectedly, and I can't run at full processing speed even when I'm technically running"

Amara recognized the allostatic load phenomenology before she had the clinical language for it. She consulted the chapter that evening.

Allostatic load is not simply stress. It is what happens when the stress response system is activated chronically without adequate recovery. The biological markers are real: elevated inflammatory cytokines, disrupted cortisol rhythms, immune suppression, accelerated cellular aging. The subjective experience — exhaustion, cognitive fog, emotional flatness, physical symptoms without clear medical etiology — is not psychosomatic in the dismissive sense. It is the physiological consequence of sustained overactivation. The body is communicating what the mind learned to override.

In the third session, Amara offered the biopsychosocial framework directly.

"I want to try a different way of understanding what's happening. Not stress as a psychological concept, but as a physiological one."

She described the HPA axis. Cortisol. Allostatic load. The body's cost accounting for chronic activation without recovery. She drew it simply — not a lecture, but a shared map.

Andrea listened. At the end: "So you're saying my body isn't broken. It's doing what bodies do when you run them past empty for two years."

"That's a good way to say it."

"And the way through is not more willpower."

"The way through is graduated recovery — rebuilding the physiological capacity that's been depleted. Which includes sleep, movement, social connection, and learning to take the foot slightly off the accelerator."

Andrea was quiet. Then: "My doctor told me this might be depression."

"Depression and what you're describing can overlap significantly. Allostatic load disrupts the same neurotransmitter and inflammatory systems that are dysregulated in depression. The distinction isn't always clinically meaningful — what matters is whether addressing the underlying physiology helps the symptoms."

"You're the first person who has made this feel like a real thing."

Amara brought the case to Marcus at their next supervision meeting. Marcus: "How did you conceptualize the case?"

Amara: "Grief plus occupational stress plus no recovery built into the structure. The fatigue is real — it's a physiological consequence, not a somatization of something psychological. The biopsychosocial model lets me treat the biological reality without dismissing the psychological context, and vice versa."

Marcus: "What's your treatment direction?"

"Psychoeducation about the physiological model — she needed to have her experience named accurately before any intervention felt legitimate. Then graduated behavioral activation with a strong recovery structure: sleep priority, three walks per week as a starting dose, one social engagement per week as a target, and grief processing work because the mother's death was never adequately metabolized."

Marcus: "That's solid clinical thinking."

The Peer Group Application

Amara brought the biopsychosocial model to the peer group in late March.

The group had been meeting for six months. Sasha, Diana, Tomás, and Amara — all in different practicum placements. They had developed a rhythm: each session opened with a brief case consultation, then a broader discussion.

Amara presented the Andrea case without identifying details. The question she brought: "How do we assess for allostatic load in a client who has been seen medically without explanation? And when is it appropriate to offer a biopsychosocial reframe to someone who has already been through extensive medical evaluation?"

Diana: "The medical workup question is important. We need to be careful about confirming psychosomatic attribution when there might be an undetected medical condition."

Amara: "Agreed. The threshold I've been using: comprehensive workup already complete, multiple systems investigated, client previously open to the connection but feeling dismissed. In that context, offering the physiological mechanism — not 'it's in your head,' but 'your body has been running a tab' — is different from telling someone their fatigue is psychological before they've had proper medical evaluation."

Tomás: "I have a client I think fits this profile. What's the entry point?"

Amara: "For Andrea, it was the two-year history timeline. Identifying what was happening before the symptoms started. Then drawing the line between the events and the physiology — not as explanation that dismisses, but as explanation that validates."

Sasha: "The client feeling validated mattered?"

"Enormously. She'd been through four specialists. Every appointment felt like being told she wasn't really sick. Naming the physiological mechanism accurately — 'your body is doing what bodies do' — gave her something real to work with."

The group spent 40 minutes on the model. Tomás brought a second case. Diana described a client where she had not thought to assess for occupational stressors before the onset of physical symptoms — and now, hearing the framework, recognized that she should go back and take a more complete history.

Amara noticed what was happening in the group: the biopsychosocial model was functioning as a clinical organizing framework that expanded everyone's conceptual space. Not because it was new — they had all learned the model in coursework — but because they were now applying it to real cases, where the theoretical tidiness of the model encountered the complexity of an actual human being.

She wrote in her journal that evening: The biopsychosocial model sounds obvious until you're sitting with someone who has been told their very real symptoms are psychosomatic — and then you have to explain that psychosomatic is not the word for what you mean, and the word you mean is 'integrated,' and the integrated system is the body and mind and relationship and history and all of it at once.

Discussion Questions

Amara recognized that clinical work has a physiological substrate — that empathic attunement activates the same systems as stress responses. What does this suggest about how clinical training should address self-care, beyond the typical psychological framing of vicarious traumatization?
Amara's experiment — walking home after activating sessions rather than taking the bus — produced a consistent pattern. How does this illustrate the concept of exercise as emotional regulation, and how might the BDNF mechanism explain what she was observing?
Andrea's experience — fatigue with no medical explanation, multiple specialist evaluations, feeling dismissed — is common for people experiencing allostatic load. What is the clinical and ethical significance of offering the physiological mechanism ("your body is doing what bodies do") rather than attributing symptoms to psychological causes?
Amara told Andrea: "The way through is not more willpower." How does the allostatic load framework reframe the traditional advice for chronic stress management, and why might this reframe be essential before any behavioral intervention can succeed?
The peer group session showed the biopsychosocial model functioning differently when applied to real cases versus learned theoretically. What does this suggest about how clinical conceptual frameworks are actually integrated into practice?