SUDS and E/RP

Trying to quantify emotional distress can be very difficult as there is an inherent subjectivity to each individual’s experiences and perceptions. When does a behavior cross from being a habit to being a ritual? When does discomfort cross the threshold to becoming distress? What if these things don’t seem to be causing impairment?

When working through anxieties and depression from a cognitive behavioral perspective, there is an emphasis placed on the subjectivity of an individual’s experience. During the course of treatment, clients may be asked to assess the difficulty of a particular behavioral exercise or the intensity of their negative emotions. There is no correct answer. These ratings are a means of gauging an individual’s subjective experience. What is overwhelming to one person may be a breeze to another. This is where the concept of Subjective Units of Distress (SUDs) comes into play. It is similar to the pain scale used at the hospital. Individuals are asked to rate their experiences on a scale – often 1-10. The lower the number, the less distress associated with the activity. The higher the number, the more distress. A one or a two would indicate that there would be little difficulty with completing a particular task or refraining from completing a ritualistic behavior. The middle of the scale, four to six, suggests that it would be a struggle and would cause a fair amount of distress but it wouldn’t be the end of the world. A ten would be completely overwhelming.

What is so impressive about the SUDs rating scale is that the ratings given to items or activities will shift over time. What may originally start out as a seven may, over time, shift down to a three. How does this happen? Remember, these ratings are not absolute but subjective evaluations based on an individual’s perceptions and experiences.

Through the practice of Exposure and Response Prevention (E/RP), a fundamental CBT approach, it is possible to get used to the levels of discomfort to the point where they are no longer bothersome. Imagine a swimming pool. A child stands on the edge and dips her toe in the water. “Brrrr! It’s cold!” She runs away from the pool only to come back a few minutes later. “Brrrr! It’s still cold!” If she continues this toe dipping and running away, she’ll never get in the pool. But, if she goes over to the shallow end where there are steps, she can gradually ease herself into the water. She goes onto the first step where the water laps at her ankles. “Brrrr! It’s cold!” However, if she stands on that step for a few minutes, the water will stop feeling so cold. Then she progresses to the second step. “Brrrr! It’s cold again, but I managed it on the first step so I can manage it again.” This process repeats itself until the child has worked her way down the steps and fully into the water. After playing in the water for a while, she likely would deny that the water was ever cold at all. “The water’s fine! Come on in!” Now the water’s temperature has not changed at all. It was the girl who habituated to the experience – her body got used to the sensations. Similarly, individuals facing paralyzing anxiety can get used to the emotional discomfort of working through their fears, provided they work through it in a methodical and SUDs-sensitive manner.

There are a number of ways to keep track of subjective distress while dealing with the therapeutic process. Whenever there is a opportunity to expose oneself to a fear, stop and assess the level of anxiety associated with going into the activity. How difficult or painful is this task going to be? Then, during the actual activity itself, what is happening to the SUDs? Is it going up or coming down? Are there spikes when dealing with particular items? What about after the task has been completed or put aside? Does the anxiety linger? Does it gradually taper off as more time passes? Is there more anxiety associated with regret and doubt about decisions made?

All these questions are important to ask as they help with assessing the appropriateness if a given task. Ideally, ones SUDs would be pretty constant during the activity itself, perhaps coming down as the activity progresses. Then the distress would continue to come down further as there is more time and distance put between the individual and the activity. Even with all this habituation, there is still going to be some emotional distress. The process of intentionally exposing oneself to feared situations likely will not pleasurable. If it was easy to face these anxiety-provoking thoughts and situations then they wouldn’t be triggering anxiety, the worries likely would not have lingered for so long.