SUDS-Guided Exposure Pacing

SUDS-Guided Exposure Pacing

A micro-intervention where the therapist uses real-time SUDS ratings to pace imaginal exposure: pausing only for brief regulation, prompting continuation at SUDS < 90, and reinforcing tolerance at peaks.

Prompt

Monitor SUDS continuously during imaginal exposure. If client reports SUDS ≥ 70 or shows visible distress (e.g., sweating, tearfulness, pause), immediately check SUDS. If SUDS is < 90 and client is responsive, gently prompt continuation ('You're doing great; keep going') and normalize safety ('It's just a memory—you are safe here'). If SUDS remains ≥ 90 after 10–15 seconds of grounding, briefly validate and recheck; do not extend pause beyond 20 seconds unless dissociation or medical concern is evident. Reinforce effort and tolerance after each segment, especially post-peak.

Objective

Maintain therapeutic exposure dose while preventing overwhelm via moment-to-moment SUDS-informed timing decisions.

Applicable Signals

• SUDS rating reported verbally
• Pause longer than 5 seconds during narration
• Autonomic signs: sweating, trembling, rapid breathing, tearfulness

Contraindications

• Client is dissociated or unresponsive to verbal prompts
• SUDS is unstable due to acute medical issue
• Client explicitly requests stop without rationale

Intervention Moves

• SUDS check on pause or distress cue
• Brief normalization + safety reminder
• Time-limited encouragement to resume
• Post-segment reinforcement tied to tolerance, not outcome

Workflow Steps

• Observe for distress cue or spontaneous pause.
• Ask: 'What’s your SUDS right now?' — wait for verbal response.
• If SUDS < 90 and client is oriented: say 'You're doing great; keep going' + 'Remember, it’s just a memory — you’re safe here.'
• If SUDS ≥ 90: hold 10–15 sec, then recheck; if still ≥ 90, offer one breath and recheck once more — then decide whether to continue or pause briefly.
• After resumption or completion of segment, name effort: 'I know how hard that was — you stayed with it.'

Constraints

• Do not pause longer than 20 seconds unless safety assessment indicates need
• Do not proceed if client is nonverbal or disoriented
• SUDS must be confirmed verbally—not assumed from behavior alone

Cautions

• Avoid reassurance that minimizes experience (e.g., 'It’s over now')—instead anchor in present safety and agency
• Never override explicit stop request—even if rationale seems insufficient
• If SUDS spikes to 100 and remains there across two checks, consider short break and collaborative re-engagement

Output Contract

• Client resumes narration within 15 seconds after SUDS check, with no escalation beyond prior peak SUDS value.

Example Therapist Responses

Example 1

• Client/Input: Client pauses mid-narrative, sweating, SUDS reported as 100.
• Therapist/Output: Therapist: 'What’s your SUDS right now?' → Client: '100.' → Therapist: 'You’re doing great — keep going. Remember, it’s just a memory; you’re safe here.'
• Notes: Prompt occurs within 5 sec of pause; no delay for regulation unless SUDS remains ≥ 90 after 15 sec.

Example 2

• Client/Input: Client says 'I can’t go on' after SUDS 70, tearful but oriented.
• Therapist/Output: Therapist: 'I know how hard that was — you did a great job staying with it so far. Would you like to try continuing from where you left off?'
• Notes: Reinforcement precedes invitation; avoids pressure while preserving exposure frame.

Files

• references/evidence.md
• references/evidence_manifest.json

Triggers

• Client reports SUDS ≥ 70 during memory narration
• Client pauses mid-narrative with visible distress (sweating, tearfulness)
• Therapist observes physiological arousal cues

Examples

Example 1

Input:

Client pauses mid-narrative, sweating, SUDS reported as 100.

Output:

Therapist: 'What’s your SUDS right now?' → Client: '100.' → Therapist: 'You’re doing great — keep going. Remember, it’s just a memory; you’re safe here.'

Notes:

Prompt occurs within 5 sec of pause; no delay for regulation unless SUDS remains ≥ 90 after 15 sec.

Example 2

Input:

Client says 'I can’t go on' after SUDS 70, tearful but oriented.

Output:

Therapist: 'I know how hard that was — you did a great job staying with it so far. Would you like to try continuing from where you left off?'

Notes:

Reinforcement precedes invitation; avoids pressure while preserving exposure frame.