Exposure Hot Spot Identification Protocol

A therapist micro-skill to identify, label, and flag high-arousal moments ('hot spots') within a trauma narrative during imaginal exposure for later targeted processing.

Prompt

While conducting imaginal exposure, observe for three objective behavioral/physiological markers: (1) unprovoked pause >5 seconds, (2) acute somatic response (e.g., sweating, tearfulness, voice breaking), or (3) SUDS spike ≥30 points within one narrative clause. When any occurs, silently note the exact phrase or timestamp in session notes as a hot spot (e.g., 'truck hits left door — son’s seat'). Only name it aloud if client is stable and ready for meta-cognitive reflection; otherwise, withhold labeling to preserve exposure flow.

Objective

Systematically detect and document narrative segments that elicit disproportionate distress or physiological reactivity to prioritize in subsequent sessions.

Applicable Signals

• unprompted pause >5 sec
• sweating/tearfulness/voice break
• SUDS Δ ≥30 in one clause

Contraindications

• Client is narrating calmly with stable SUDS
• Therapist has not yet established baseline SUDS anchors
• Client explicitly resists labeling or revisiting parts of memory

Intervention Moves

• silent timestamp/phrase notation
• optional verbal naming only if client shows readiness for meta-cognition

Workflow Steps

• Observe for ≥1 applicable signal during exposure
• Confirm signal is not prompted by therapist interruption
• Record precise narrative phrase or timestamp as hot spot in notes
• Withhold verbal labeling unless client demonstrates cognitive stability and openness

Constraints

• Must occur during active imaginal exposure
• Requires pre-established SUDS scale anchoring
• No interpretation or reframing permitted at this step

Cautions

• Do not interrupt exposure flow to label; delay naming until natural pause or post-exposure debrief
• Avoid premature meta-cognitive framing if client is still in state-dependent arousal

Output Contract

• A timestamped or verbatim-quoted hot spot annotation in session notes (e.g., 'truck hits back left door — son’s seat'), with optional real-time verbal naming only if client is cognitively accessible and consents to reflection.

Example Therapist Responses

Example 1

• Client/Input: Client pauses 8 seconds after saying 'The truck hits us on the back left side door...'
• Therapist/Output: Therapist notes in chart: 'Hot spot: "truck hits back left door — son’s seat"', no verbal comment
• Notes: Pause exceeds 5 sec; somatic signs present (sweating, tearful); SUDS rose from 100→70 mid-pause — qualifies as hot spot.

Example 2

• Client/Input: Client says 'My son was sitting there' and begins sobbing uncontrollably, SUDS jumps from 60 to 95
• Therapist/Output: Therapist writes: 'Hot spot: "son was sitting there"', then says gently: 'That part came up strongly — we’ll come back to it.'
• Notes: SUDS Δ = 35; acute somatic response; therapist names only briefly and future-oriented to avoid re-traumatizing.

Objective

Systematically detect and document narrative segments that elicit disproportionate distress or physiological reactivity to prioritize in subsequent sessions.

Applicable Signals

• unprompted pause >5 sec
• sweating/tearfulness/voice break
• SUDS Δ ≥30 in one clause

Contraindications

• Client is narrating calmly with stable SUDS
• Therapist has not yet established baseline SUDS anchors
• Client explicitly resists labeling or revisiting parts of memory

Intervention Moves

• silent timestamp/phrase notation
• optional verbal naming only if client shows readiness for meta-cognition

Workflow Steps

• Observe for ≥1 applicable signal during exposure
• Confirm signal is not prompted by therapist interruption
• Record precise narrative phrase or timestamp as hot spot in notes
• Withhold verbal labeling unless client demonstrates cognitive stability and openness

Constraints

• Must occur during active imaginal exposure
• Requires pre-established SUDS scale anchoring
• No interpretation or reframing permitted at this step

Cautions

• Do not interrupt exposure flow to label; delay naming until natural pause or post-exposure debrief
• Avoid premature meta-cognitive framing if client is still in state-dependent arousal

Output Contract

• A timestamped or verbatim-quoted hot spot annotation in session notes (e.g., 'truck hits back left door — son’s seat'), with optional real-time verbal naming only if client is cognitively accessible and consents to reflection.

Example Therapist Responses

Example 1

• Client/Input: Client pauses 8 seconds after saying 'The truck hits us on the back left side door...'
• Therapist/Output: Therapist notes in chart: 'Hot spot: "truck hits back left door — son’s seat"', no verbal comment
• Notes: Pause exceeds 5 sec; somatic signs present (sweating, tearful); SUDS rose from 100→70 mid-pause — qualifies as hot spot.

Example 2

• Client/Input: Client says 'My son was sitting there' and begins sobbing uncontrollably, SUDS jumps from 60 to 95
• Therapist/Output: Therapist writes: 'Hot spot: "son was sitting there"', then says gently: 'That part came up strongly — we’ll come back to it.'
• Notes: SUDS Δ = 35; acute somatic response; therapist names only briefly and future-oriented to avoid re-traumatizing.

Files

• references/evidence.md

• references/evidence_manifest.json

Triggers

• Client pauses unusually long (>5 sec) during memory narration
• Client displays acute somatic response (sweating, tearfulness, voice breaking) without prompting
• SUDS spikes ≥30 points within one narrative clause

Examples

Example 1

Input:

Client pauses 8 seconds after saying 'The truck hits us on the back left side door...'

Output:

Therapist notes in chart: 'Hot spot: "truck hits back left door — son’s seat"', no verbal comment

Notes:

Pause exceeds 5 sec; somatic signs present (sweating, tearful); SUDS rose from 100→70 mid-pause — qualifies as hot spot.

Example 2

Input:

Client says 'My son was sitting there' and begins sobbing uncontrollably, SUDS jumps from 60 to 95

Output:

Therapist writes: 'Hot spot: "son was sitting there"', then says gently: 'That part came up strongly — we’ll come back to it.'

Notes:

SUDS Δ = 35; acute somatic response; therapist names only briefly and future-oriented to avoid re-traumatizing.