What is the Subjective Units of Distress Scale?

Introduction

A Subjective Units of Distress Scale (SUDS), also known as the Subjective Units of Disturbance Scale), is a scale ranging from 0 to 10 measuring the subjective intensity of disturbance or distress currently experienced by an individual.

Respondents provide a self report of where they are on the scale. The SUDS may be used as a benchmark for a professional or observer to evaluate the progress of treatment. In desensitisation-based therapies, and the patients’ regular self assessments enable them to guide the clinician repeatedly as part of the therapeutic dialogue.

The SUD-level was developed by Joseph Wolpe in 1969. It has been used in cognitive-behavioural treatments for anxiety disorders (e.g. exposure practices and hierarchy) and for research purposes.

There is no hard and fast rule by which a patient can self assign a SUDS rating to his or her disturbance or distress, hence the name subjective.

Some guidelines are:

  • The intensity recorded must be as it is experienced now.
  • Constriction or congestion or tensing of body parts indicates a higher SUDS than that reported.

The Scale

There a number of version of the scale, and the below is for illustration only:

  • 10 = Feels unbearably bad, beside yourself, out of control as in a nervous breakdown, overwhelmed, at the end of your rope. You may feel so upset that you don’t want to talk because you can’t imagine how anyone could possibly understand your agitation.
  • 9 = Feeling desperate. What most people call a 10 is actually a 9. Feeling extremely freaked out to the point that it almost feels unbearable and you are getting scared of what you might do. Feeling very, very bad, losing control of your emotions.
  • 8 = Freaking out. The beginning of alienation.
  • 7 = Starting to freak out, on the edge of some definitely bad feelings. You can maintain control with difficulty.
  • 6 = Feeling bad to the point that you begin to think something ought to be done about the way you feel.
  • 5 = Moderately upset, uncomfortable. Unpleasant feelings are still manageable with some effort.
  • 4 = Somewhat upset to the point that you cannot easily ignore an unpleasant thought. You can handle it OK but don’t feel good.
  • 3 = Mildly upset. Worried, bothered to the point that you notice it.
  • 2 = A little bit upset, but not noticeable unless you took care to pay attention to your feelings and then realize, “yes” there is something bothering me.
  • 1 = No acute distress and feeling basically good. If you took special effort you might feel something unpleasant but not much.
  • 0 = Peace, serenity, total relief. No more anxiety of any kind about any particular issue.

Utility Does Not Require Precision

In using SUDS in a therapeutic setting, the therapist does not necessarily define the scale, because one of the benefits of asking a patient or client for a SUDS score is that it is simple. Typically, you can ask the client, “On a scale of zero to ten, where zero is the best you can feel and ten is the worst, how do you feel right now?”

The purpose of this question is to enable the patient or client to notice improvements, and the inherent difference between one person’s subjective scale and another person’s is irrelevant to therapy with either individual. Our brains are sophisticated enough that they can usually summarize a large amount of data very quickly, and often accurately.

There is a possibility that in some forms of therapy, the patient will want to see progress and will therefore report progress that isn’t objectively present – a type one error from a statistical point of view. While both type I and type II errors are important in research situations, type one errors can have a therapeutic utility in clinical situations, in which they can provide an indirect opportunity for positive autosuggestion – much like the indirect suggestions employed in Eriksonian hypnosis.

Thus, since the main use of SUDS is for clinical purposes, rather than research purposes, the imprecise nature of the scale is relatively unimportant to its main users: patients and clinicians.

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Who was Joseph Wolpe?

Introduction

Joseph Wolpe (20 April 1915 to 4 December 1997 in Los Angeles) was a South African psychiatrist and one of the most influential figures in behaviour therapy.

Wolpe grew up in South Africa, attending Parktown Boys’ High School and obtaining his MD from the University of the Witwatersrand.

In 1956, Wolpe was awarded a Ford Fellowship and spent a year at Stanford University in the Center for Behavioral Sciences, subsequently returning to South Africa but permanently moving to the United States in 1960 when he accepted a position at the University of Virginia.

In 1965, Wolpe accepted a position at Temple University.

One of the most influential experiences in Wolpe’s life was when he enlisted in the South African army as a medical officer. Wolpe was entrusted to treat soldiers who were diagnosed with what was then called “war neurosis” but today is known as post traumatic stress disorder. The mainstream treatment of the time for soldiers was based on psychoanalytic theory, and involved exploring the trauma while taking a hypnotic agent – so-called narcotherapy. It was believed that having the soldiers talk about their repressed experiences openly would effectively cure their neurosis. However, this was not the case. It was this lack of successful treatment outcomes that forced Wolpe, once a dedicated follower of Freud, to question psychoanalytic therapy and search for more effective treatment options. Wolpe is most well known for his reciprocal inhibition techniques, particularly systematic desensitisation, which revolutionised behavioural therapy. A Review of General Psychology survey, published in 2002, ranked Wolpe as the 53rd most cited psychologist of the 20th century, an impressive accomplishment accentuated by the fact that Wolpe was a psychiatrist.

Reciprocal Inhibition

In Wolpe’s search for a more effective way in treating anxiety he developed different reciprocal inhibition techniques, utilising assertiveness training. Reciprocal inhibition can be defined as anxiety being inhibited by a feeling or response that is not compatible with the feeling of anxiety. Wolpe first started using eating as a response to inhibited anxiety in the laboratory cats. He would offer them food while presenting a conditioned fear stimulus. After his experiments in the laboratory he applied reciprocal inhibition to his clients in the form of assertiveness training. The idea behind assertiveness training was that you could not be angry or aggressive while simultaneously assertive at same time. Importantly, Wolpe believed that these techniques would lessen the anxiety producing association. Assertiveness training proved especially useful for clients who had anxiety about social situations. However, assertiveness training did have a potential flaw in the sense that it could not be applied to other kinds of phobias. Wolpe’s use of reciprocal inhibition led to his discovery of systematic desensitisation. He believed that facing your fears did not always result in overcoming them but rather lead to frustration. According to Wolpe, the key to overcoming fears was “by degrees”.

Systematic Desensitisation

Systematic desensitisation is what Wolpe is most famous for. Systematic desensitisation is when the client is exposed to the anxiety-producing stimulus at a low level, and once no anxiety is present a stronger version of the anxiety-producing stimulus is given. This continues until the individual client no longer feels any anxiety towards the stimulus. There are three main steps in using systematic desensitization, following development of a proper case formulation or what Wolpe originally called, “behaviour analysis“. The first step is to teach the client relaxation techniques.

Wolpe received the idea of relaxation from Edmund Jacobson, modifying his muscle relaxation techniques to take less time. Wolpe’s rationale was that one cannot be both relaxed and anxious at the same time. The second step is for the client and the therapist to create a hierarchy of anxieties. The therapist normally has the client make a list of all the things that produce anxiety in all its different forms. Then together, with the therapist, the client makes a hierarchy, starting with what produces the lowest level of anxiety to what produces the most anxiety. Next is to have the client be fully relaxed while imaging the anxiety producing stimulus. Depending on what their reaction is, whether they feel no anxiety or a great amount of anxiety, the stimulus will then be changed to a stronger or weaker one. Systematic desensitisation, though successful, has flaws as well. The patient may give misleading hierarchies, have trouble relaxing, or not be able to adequately imagine the scenarios. Despite this possible flaw, it seems to be most successful.

Achievements

Wolpe’s effect on behavioural therapy is long-lasting and extensive. He received many awards for his work in behavioural science. His awards included the American Psychological Associations Distinguished Scientific Award, the Psi Chi Distinguished Member Award, and the Lifetime Achievement Award from the Association for the Advancement of Behaviour Therapy, where he was the second president. In addition to these awards, Wolpe’s alma mater, University of Witwatersrand, awarded him an honorary doctor of science degree in 1986. Furthermore, Wolpe was a prolific writer, some of his most famous books include, The Practice of Behaviour Therapy and Psychotherapy by Reciprocal Inhibition. Joseph Wolpe’s dedication to psychology is clear in his involvement in the psychology community, a month before his death he was attending conferences and giving lectures at Pepperdine University even though he was retired. Moreover, his theories have lasted well beyond his death.

Wolpe developed the Subjective Units of Disturbance Scale (SUDS) for assessing the level of subjective discomfort or psychological pain. He also created the Subjective Anxiety Scale (SAS) and the Fear Survey Plan that are used in behaviour research and therapy.

Wolpe died in 1997 of mesothelioma.