SUDS-Guided Exposure Pacing

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.

Prompt

Elicit SUDS mid-exposure; interpret the value in context of expected distress trajectory; normalize it verbally; then explicitly state the next behavioral step (e.g., 'stay here for 30 more seconds', 'let’s pause and ground', or 'try that segment again') — all while maintaining empathic presence and safety framing.

Objective

Anchor exposure delivery to client’s subjective distress level to maintain therapeutic window and prevent overwhelm.

Applicable Signals

• SUDS ≥70 during memory narration
• physiological signs of arousal (tearfulness, sweating, shallow breathing)
• narrative pause longer than 5 seconds without prompting

Contraindications

• Client refuses SUDS self-reporting
• Client is dissociated or non-responsive
• SUDS scale has not been previously calibrated with the client

Intervention Moves

• eliciting SUDS with open timing ('What’s your SUDS right now?')
• normalizing the rating ('That’s expected at this point')
• linking rating to action ('You’re at 100 — let’s stay here for 30 more seconds before checking again')

Workflow Steps

• 1. Elicit current SUDS rating using standardized 0–100 scale
• 2. Acknowledge and normalize the rating in relation to exposure phase
• 3. Observe behavioral and physiological cues for congruence
• 4. Verbally name the rating and explicitly state the next micro-action (continue, pause, repeat, or ground)
• 5. Confirm client’s capacity to proceed (e.g., 'Are you ready to keep going?')

Constraints

• Must occur only after SUDS scale has been introduced and practiced in prior session(s)
• SUDS check must be timed mid-narrative—not only at start/end
• No interpretation beyond normalization and action-linking; avoid reassurance or premature reframing

Cautions

• Avoid interpreting SUDS as 'progress' or 'failure'; treat it solely as pacing data
• Do not override client’s expressed inability to continue, even if SUDS is <70
• If SUDS drops rapidly (<30 sec), verify grounding status before proceeding

Output Contract

• Therapist names the SUDS value, normalizes it, and explicitly links next action — and client resumes narrative or confirms readiness.

Example Therapist Responses

Example 1

• Client/Input: Client: 'The truck hits us on the back left side door... (pauses, sweating)'
• Therapist/Output: Therapist: 'What’s your SUDS right now?'
• Notes: SUDS elicitation triggered by pause + physiological cue

Example 2

• Client/Input: Client: '100.'
• Therapist/Output: Therapist: 'That’s completely expected at this part — let’s stay right here for 30 more seconds, then check again.'
• Notes: Normalization + time-bound continuation directive

Example 3

• Client/Input: Client: '70.'
• Therapist/Output: Therapist: 'I know how hard that was — you did a great job. Are you ready to try that part again?'
• Notes: Validation + explicit invitation to repeat

Objective

Anchor exposure delivery to client’s subjective distress level to maintain therapeutic window and prevent overwhelm.

Applicable Signals

• SUDS ≥70 during memory narration
• physiological signs of arousal (tearfulness, sweating, shallow breathing)
• narrative pause longer than 5 seconds without prompting

Contraindications

• Client refuses SUDS self-reporting
• Client is dissociated or non-responsive
• SUDS scale has not been previously calibrated with the client

Intervention Moves

• eliciting SUDS with open timing ('What’s your SUDS right now?')
• normalizing the rating ('That’s expected at this point')
• linking rating to action ('You’re at 100 — let’s stay here for 30 more seconds before checking again')

Workflow Steps

• 1. Elicit current SUDS rating using standardized 0–100 scale
• 2. Acknowledge and normalize the rating in relation to exposure phase
• 3. Observe behavioral and physiological cues for congruence
• 4. Verbally name the rating and explicitly state the next micro-action (continue, pause, repeat, or ground)
• 5. Confirm client’s capacity to proceed (e.g., 'Are you ready to keep going?')

Constraints

• Must occur only after SUDS scale has been introduced and practiced in prior session(s)
• SUDS check must be timed mid-narrative—not only at start/end
• No interpretation beyond normalization and action-linking; avoid reassurance or premature reframing

Cautions

• Avoid interpreting SUDS as 'progress' or 'failure'; treat it solely as pacing data
• Do not override client’s expressed inability to continue, even if SUDS is <70
• If SUDS drops rapidly (<30 sec), verify grounding status before proceeding

Output Contract

• Therapist names the SUDS value, normalizes it, and explicitly links next action — and client resumes narrative or confirms readiness.

Example Therapist Responses

Example 1

• Client/Input: Client: 'The truck hits us on the back left side door... (pauses, sweating)'
• Therapist/Output: Therapist: 'What’s your SUDS right now?'
• Notes: SUDS elicitation triggered by pause + physiological cue

Example 2

• Client/Input: Client: '100.'
• Therapist/Output: Therapist: 'That’s completely expected at this part — let’s stay right here for 30 more seconds, then check again.'
• Notes: Normalization + time-bound continuation directive

Example 3

• Client/Input: Client: '70.'
• Therapist/Output: Therapist: 'I know how hard that was — you did a great job. Are you ready to try that part again?'
• Notes: Validation + explicit invitation to repeat

Files

• references/evidence.md

• references/evidence_manifest.json

Triggers

• 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

Examples

Example 1

Input:

Client: 'The truck hits us on the back left side door... (pauses, sweating)'

Output:

Therapist: 'What’s your SUDS right now?'

Notes:

SUDS elicitation triggered by pause + physiological cue

Example 2

Input:

Client: '100.'

Output:

Therapist: 'That’s completely expected at this part — let’s stay right here for 30 more seconds, then check again.'

Notes:

Normalization + time-bound continuation directive

Example 3

Input:

Client: '70.'

Output:

Therapist: 'I know how hard that was — you did a great job. Are you ready to try that part again?'

Notes:

Validation + explicit invitation to repeat