Learning Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians

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Last Updated Nov 11, 2022|

Processing Emotional Hot Spots for PTSD: Introduction

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • The hot spots are the most currently distressing parts of the trauma.
  • We pick 1 hot spot to begin with and repeat that 1 part of the memory to wear it out.
  • When that part seems to have been sufficiently processed, we’ll move on to the next hot spot.

 

Transcript

Video 3: Introduction to the hot spots procedure.
The hot spots are the most currently distressing parts of the trauma.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Beginning at about session 5 or 6, emotional processing of the trauma memories can be made more efficient by having the patient focus primarily or exclusively on these hot spots during the exposure. We introduce this procedure after the homework review.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

During this introduction, we can explain to the patient, “Up to this point, each time you’ve revisited the trauma, you’ve described the entire memory of your trauma.” And again, use the words that the patient uses to describe their trauma. “Today, we’re going to use a different procedure that helps to emotionally process the most difficult moments.”

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

“I will ask you to tell me—based on your last exposure here and on your listening to the imaginal exposure recording last week—what the most distressing or upsetting parts of this memory are for you now. What are the hardest parts now? Then I’ll ask you to focus the revisiting and recounting on each of these hotspots, 1 at a time. We’ll pick 1 to begin with and you’ll repeat that 1 part of the memory over and over just by itself, focusing in closely and describing what happened in great detail—as if in slow motion—including what you felt, saw, heard, and thought. We will repeat it as many times as necessary to wear it out or bring about a big decrease in your SUDS level. When that part seems to have been sufficiently processed, we’ll move on to the next one. It’s similar to when you get a massage. Sometimes, there’s a knot and the masseuse focuses on that knot for a while. It might hurt, but when that knot is worked out, then they can work on the whole area again and it’s smoother.”

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Identifying the hot spots: You can start this conversation by asking, “When you did the revisiting last session?” or “When you listened to the recording this week for homework, what was the hardest part?” You can use the patient’s self-report of the currently most distressing moments of the traumatic memory. If the patient doesn’t identify a part of the memory that in your perception is likely a hot spot and that’s where the part where the patient always gives the highest SUDS ratings or avoids that part somewhat during the exposure or you can see that they get the most distressed, ask him whether that part is a hot spot as well. You can then decide together what hot spot would be the best to focus on first.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

In my sessions, I am recording their SUDS level on my sheet. And very often, I am making notes to myself about what might be a hot spot—especially when I see them avoiding or having a lot of distress around that moment time after time. It’s helpful for the therapist to be paying attention in these earlier sessions to what might be a hot spot. It’s also helpful in session 4, if you think the next session, you’ll start hot spots, to orient the patient to notice when they’re practicing the homework to pay attention to what are the hardest parts for them.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Selecting a hot spot to begin the exposure: The hot spot to focus on first should be the worst one—the most distressing part of the trauma. Be sure to only include 1 hot spot and to determine the beginning and the end of the hot spot. So, just like we determined the beginning and end of the narrative for the exposure, you want to determine the beginning and end of the hot spot for this 1 slice.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Ideally, it should be a very brief slice of time that can be easily repeated. If there is another hot spot that closely follows, you can revisit that after completing this hot spot. We only work on 1 hot spot in each session.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Some examples of hot spots.

I remember one young woman I worked with who was a rape survivor when she was 19 and in college. She was raped and she had gone through the memory several times and in several sessions. And when we got to the hot spot, it was the first time that she recalled that he had forced her or was telling her to perform fellatio. She was refusing. He had a gun and he cocked the gun and said if she didn’t perform fellatio, he would kill her. And he had the gun at her head. And she only remembered that and recounted it during the hot spot. And then we went over it and over it.

And at the end of the treatment for her, she described—I always love her description—that therapy was like an onion and that we kept peeling off layers. And then when we got to the middle part, the stinky part, and for her that was the hot spot. It was like we released the stinky part and then it didn’t stink anymore.

I had another patient who actually was also a rape survivor in college. She went to get gas at night and was abducted. And he drove her car to an abandoned lot and they got out and he raped her every which way in that abandoned lot. And they get back in her car and she thought it was over and she thought that she was going to get to go home. And he took her to an abandoned house.
And when we got to the hot spot, it was of going in that house because she said, “I thought when he took me in that house that the next time my parents would see me would be in a coffin. I didn’t think I was coming out.” And so that was the hot spot for her that we worked on.

Another analogy that one of my patients used that I love: So, she was at least as old as I am and it was because we remembered the old long-playing records, LPs, vinyl records that you would play on a record player. And the way she described hot spots at the end of therapy—because at the last session, we’ll put the memory back together again—she said working on the hotspots was like we played the record and the parts that skipped that we worked on each of those for a hot spot. And then at the end, we could play the whole record through again and it didn’t skip. So, I always love that analogy as well.

Key points from this video are the hot spots are the most currently distressing parts of the trauma. We pick 1 hot spot to begin with and you’ll repeat that 1 part of the memory over and over just by itself, focusing in closely and describing what happened in great detail—as if in slow motion—including what the patient felt, saw, heard, and thought. We’ll repeat it as many times as necessary in that session and in other sessions to wear it out or bring about a big decrease in SUDS. When that part seems to have been sufficiently processed, we’ll move on to the next hot spot.

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