Imaginal Exposure Session Scaffold

A structured session framework for delivering imaginal exposure therapy to PTSD clients, guiding the therapist through memory narration, sensory-emotional elaboration, and habituation-focused repetition.

Prompt

Begin by grounding the client and confirming readiness. Prompt the client to narrate the trauma memory starting from the first moment of awareness (e.g., 'When did you first realize the earthquake was happening?'). Guide them to describe location, people present, sensory details (sights, sounds, physical sensations), emotional states, and thoughts—progressively deepening detail across repetitions. Record the final narrative for homework. Maintain pacing: pause for affect regulation if distress exceeds 6/10; never force continuation.

Objective

Facilitate trauma memory processing via repeated, therapist-guided verbal recounting with progressive sensory and emotional detail

Applicable Signals

• Client avoids trauma-related topics but shows capacity for verbal reflection
• Client reports intrusive memories or avoidance that impair functioning
• Client expresses willingness to try exposure after rationale is shared

Contraindications

• Client is in acute crisis or active suicidal ideation
• Client lacks capacity to narrate coherently or regulate arousal
• No safety plan is in place

Intervention Moves

• open-ended prompting for sensory detail
• affect labeling ('You’re describing shaking hands — what emotion came with that?')
• pacing regulation ('Let’s pause here — take a breath, then continue when ready')

Workflow Steps

• Confirm client’s current safety, grounding, and consent for today’s exposure
• Prompt initiation at earliest moment of threat awareness (e.g., 'Where were you when you first felt the ground shake?')
• Guide sequential elaboration: setting → people → sensory input → bodily sensations → emotions → thoughts
• After first full recount, ask for one additional sensory or emotional detail before repeating
• Repeat narration 2–3 times in session, increasing specificity each round
• Record final version with client permission; assign as daily listening homework

Constraints

• Must occur only after psychoeducation and collaborative agreement on exposure rationale
• Therapist must monitor SUDS continuously and pause if >6/10
• Narrative must be recorded with client consent for between-session practice

Cautions

• Avoid leading questions that distort memory content
• Do not interrupt mid-narrative unless distress is escalating uncontrollably
• Never interpret meaning or introduce cognitive reframing during exposure phase

Output Contract

• A complete, therapist-verified audio-recorded trauma narrative containing location, people, sensory details, bodily sensations, emotions, and thoughts — suitable for client’s daily imaginal exposure homework.

Example Therapist Responses

Example 1

• Client/Input: Client begins narrative hesitantly: 'I was at home... and then it shook.'
• Therapist/Output: Therapist responds: 'Yes — where in the house were you? Was anyone else there? What did you hear right then?'
• Notes: Open-ended sensory anchoring to stabilize and deepen engagement.

Example 2

• Client/Input: Client reports SUDS 7/10 mid-narrative and starts breathing rapidly.
• Therapist/Output: Therapist says: 'Let’s pause — feel your feet on the floor. Breathe with me: inhale 4, hold 4, exhale 6. We’ll return to the story when you’re at 5 or below.'
• Notes: Regulation before continuation; no reinterpretation or reassurance.

Objective

Facilitate trauma memory processing via repeated, therapist-guided verbal recounting with progressive sensory and emotional detail

Applicable Signals

• Client avoids trauma-related topics but shows capacity for verbal reflection
• Client reports intrusive memories or avoidance that impair functioning
• Client expresses willingness to try exposure after rationale is shared

Contraindications

• Client is in acute crisis or active suicidal ideation
• Client lacks capacity to narrate coherently or regulate arousal
• No safety plan is in place

Intervention Moves

• open-ended prompting for sensory detail
• affect labeling ('You’re describing shaking hands — what emotion came with that?')
• pacing regulation ('Let’s pause here — take a breath, then continue when ready')

Workflow Steps

• Confirm client’s current safety, grounding, and consent for today’s exposure
• Prompt initiation at earliest moment of threat awareness (e.g., 'Where were you when you first felt the ground shake?')
• Guide sequential elaboration: setting → people → sensory input → bodily sensations → emotions → thoughts
• After first full recount, ask for one additional sensory or emotional detail before repeating
• Repeat narration 2–3 times in session, increasing specificity each round
• Record final version with client permission; assign as daily listening homework

Constraints

• Must occur only after psychoeducation and collaborative agreement on exposure rationale
• Therapist must monitor SUDS continuously and pause if >6/10
• Narrative must be recorded with client consent for between-session practice

Cautions

• Avoid leading questions that distort memory content
• Do not interrupt mid-narrative unless distress is escalating uncontrollably
• Never interpret meaning or introduce cognitive reframing during exposure phase

Output Contract

• A complete, therapist-verified audio-recorded trauma narrative containing location, people, sensory details, bodily sensations, emotions, and thoughts — suitable for client’s daily imaginal exposure homework.

Example Therapist Responses

Example 1

• Client/Input: Client begins narrative hesitantly: 'I was at home... and then it shook.'
• Therapist/Output: Therapist responds: 'Yes — where in the house were you? Was anyone else there? What did you hear right then?'
• Notes: Open-ended sensory anchoring to stabilize and deepen engagement.

Example 2

• Client/Input: Client reports SUDS 7/10 mid-narrative and starts breathing rapidly.
• Therapist/Output: Therapist says: 'Let’s pause — feel your feet on the floor. Breathe with me: inhale 4, hold 4, exhale 6. We’ll return to the story when you’re at 5 or below.'
• Notes: Regulation before continuation; no reinterpretation or reassurance.

Files

• references/evidence.md

• references/evidence_manifest.json

Triggers

• Client has confirmed PTSD diagnosis and stable baseline
• Client is voluntarily engaged and able to tolerate moderate distress
• Psychoeducation about PTSD and exposure rationale has been delivered

Examples

Example 1

Input:

Client begins narrative hesitantly: 'I was at home... and then it shook.'

Output:

Therapist responds: 'Yes — where in the house were you? Was anyone else there? What did you hear right then?'

Notes:

Open-ended sensory anchoring to stabilize and deepen engagement.

Example 2

Input:

Client reports SUDS 7/10 mid-narrative and starts breathing rapidly.

Output:

Therapist says: 'Let’s pause — feel your feet on the floor. Breathe with me: inhale 4, hold 4, exhale 6. We’ll return to the story when you’re at 5 or below.'

Notes:

Regulation before continuation; no reinterpretation or reassurance.