Imaginal Exposure Session Scaffold

A session-phase workflow for conducting imaginal exposure in PTSD treatment, specifying timing, repetition, SUDS monitoring, and therapist response patterns.

Prompt

Begin by confirming client readiness and obtaining baseline SUDS. Guide client to narrate the traumatic memory in present tense, from start to completion, without interruption. Monitor SUDS every 60–90 seconds. If distress peaks or stalls, gently encourage continuation while validating effort and safety. Repeat the full memory narrative within the same session for total exposure time ≥45 minutes. Track SUDS reduction across repetitions. End with grounding, psychoeducation on habituation, and collaborative decision about next repetition.

Objective

Reduce trauma-related distress through repeated, time-bound memory reactivation with real-time distress tracking and supportive scaffolding.

Applicable Signals

• Client verbalizes willingness to engage with memory
• Baseline SUDS < 90
• No active dissociation or autonomic dysregulation observed pre-exposure

Contraindications

• Client is actively suicidal or in acute crisis
• Client lacks memory coherence or dissociates severely during recall
• No pre-session safety plan is in place

Intervention Moves

• SUDS calibration
• Present-tense anchoring
• Non-interpretive encouragement
• Hot spot notation
• Time-bound repetition framing

Workflow Steps

• Confirm consent, review safety plan, assess baseline SUDS
• Instruct client to narrate memory in present tense, from earliest recallable moment to resolution
• Monitor SUDS every 60–90 seconds; label ratings aloud ('You're at 85 — that's high, and okay')
• Use minimal, non-directive encouragement ('Keep going', 'Stay with it', 'You're safe here') when client pauses or hesitates
• If client stops, ask: 'What’s happening right now?' — then return to narrative without analysis
• Repeat full memory narration until cumulative exposure time ≥45 minutes
• Post-exposure: normalize response, note SUDS trajectory, reinforce agency ('You chose to stay'), co-plan next step

Constraints

• Exposure must run continuously or in repeated cycles totaling ≥45 minutes
• Each full memory narration must reach its natural endpoint (e.g., 'the ambulance arrived')
• SUDS must be assessed at least every 90 seconds; if >90 for >2 minutes, pause briefly to ground before resuming

Cautions

• Avoid interpreting, reframing, or problem-solving during exposure
• Do not allow premature termination unless safety is compromised
• Mark 'hot spots' (intense affective/physiological moments) for later processing, but do not dwell on them mid-exposure

Output Contract

• Client completes ≥45 minutes of continuous or repeated imaginal exposure with observable SUDS reduction across repetitions and verbally affirms capacity to re-engage voluntarily (e.g., 'I think I could try that again').

Example Therapist Responses

Example 1

• Client/Input: Client reports SUDS 80 pre-exposure; narrates motor vehicle accident memory, pauses at impact moment (SUDS 100), resumes after therapist validation.
• Therapist/Output: Therapist notes hot spot, confirms SUDS drop to 70 post-narrative, invites repetition, client agrees.
• Notes: Demonstrates real-time SUDS tracking, hot spot identification, and voluntary re-engagement.

Example 2

• Client/Input: Client begins second repetition, reaches same hot spot, SUDS rises to 85 (vs. 100 first time), continues without pause.
• Therapist/Output: Therapist affirms reduction ('That was lower this time — your brain is learning it’s safe to remember'), logs habituation evidence.
• Notes: Shows within-session distress reduction — core success indicator.

Objective

Reduce trauma-related distress through repeated, time-bound memory reactivation with real-time distress tracking and supportive scaffolding.

Applicable Signals

• Client verbalizes willingness to engage with memory
• Baseline SUDS < 90
• No active dissociation or autonomic dysregulation observed pre-exposure

Contraindications

• Client is actively suicidal or in acute crisis
• Client lacks memory coherence or dissociates severely during recall
• No pre-session safety plan is in place

Intervention Moves

• SUDS calibration
• Present-tense anchoring
• Non-interpretive encouragement
• Hot spot notation
• Time-bound repetition framing

Workflow Steps

• Confirm consent, review safety plan, assess baseline SUDS
• Instruct client to narrate memory in present tense, from earliest recallable moment to resolution
• Monitor SUDS every 60–90 seconds; label ratings aloud ('You're at 85 — that's high, and okay')
• Use minimal, non-directive encouragement ('Keep going', 'Stay with it', 'You're safe here') when client pauses or hesitates
• If client stops, ask: 'What’s happening right now?' — then return to narrative without analysis
• Repeat full memory narration until cumulative exposure time ≥45 minutes

Constraints

• Exposure must run continuously or in repeated cycles totaling ≥45 minutes
• Each full memory narration must reach its natural endpoint (e.g., 'the ambulance arrived')
• SUDS must be assessed at least every 90 seconds; if >90 for >2 minutes, pause briefly to ground before resuming

Cautions

• Avoid interpreting, reframing, or problem-solving during exposure
• Do not allow premature termination unless safety is compromised
• Mark 'hot spots' (intense affective/physiological moments) for later processing, but do not dwell on them mid-exposure

Output Contract

• Client completes ≥45 minutes of continuous or repeated imaginal exposure with observable SUDS reduction across repetitions and verbally affirms capacity to re-engage voluntarily (e.g., 'I think I could try that again').

Example Therapist Responses

Example 1

• Client/Input: Client reports SUDS 80 pre-exposure; narrates motor vehicle accident memory, pauses at impact moment (SUDS 100), resumes after therapist validation.
• Therapist/Output: Therapist notes hot spot, confirms SUDS drop to 70 post-narrative, invites repetition, client agrees.
• Notes: Demonstrates real-time SUDS tracking, hot spot identification, and voluntary re-engagement.

Example 2

• Client/Input: Client begins second repetition, reaches same hot spot, SUDS rises to 85 (vs. 100 first time), continues without pause.
• Therapist/Output: Therapist affirms reduction ('That was lower this time — your brain is learning it’s safe to remember'), logs habituation evidence.
• Notes: Shows within-session distress reduction — core success indicator.

子技能目录

• [Exposure Hot Spot Identification Protocol](心理咨询/Family技能/行为主义/微技能/Exposure Hot Spot Identification Protocol/SKILL.md) ｜ 适用：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.
• [SUDS-Guided Exposure Pacing](心理咨询/Family技能/行为主义/微技能/SUDS-Guided Exposure Pacing/SKILL.md) ｜ 适用：A micro-intervention where the therapist uses real-time SUDS ratings to calibrate pacing, validate distress, and decide whether to continue, pause, or repeat segments of imaginal exposure.

选用规则（微技能目录）

• 当目标、阶段或方法更接近

  Exposure Hot Spot Identification Protocol

  时，优先调用它。 线索：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, imaginal exposure, PTSD
• 当目标、阶段或方法更接近

  SUDS-Guided Exposure Pacing

  时，优先调用它。 线索：Client provides a SUDS rating ≥70 mid-exposure, Client pauses or shows physiological arousal (sweating, tearfulness), Therapist observes incongruence between reported SUDS and behavioral cues, imaginal exposure, SUDS

Files

• references/children_manifest.json

• references/children_map.md

• references/evidence.md

• references/evidence_manifest.json

Triggers

• Client has confirmed PTSD diagnosis with a discrete traumatic memory
• Client is physiologically and emotionally regulated enough to tolerate memory recall
• Therapist has established safety and collaboration

Examples

Example 1

Input:

Client reports SUDS 80 pre-exposure; narrates motor vehicle accident memory, pauses at impact moment (SUDS 100), resumes after therapist validation.

Output:

Therapist notes hot spot, confirms SUDS drop to 70 post-narrative, invites repetition, client agrees.

Notes:

Demonstrates real-time SUDS tracking, hot spot identification, and voluntary re-engagement.

Example 2

Input:

Client begins second repetition, reaches same hot spot, SUDS rises to 85 (vs. 100 first time), continues without pause.

Output:

Therapist affirms reduction ('That was lower this time — your brain is learning it’s safe to remember'), logs habituation evidence.

Notes:

Shows within-session distress reduction — core success indicator.