An Illustrated SUDS Chart: Communicating Emotional Pain

Most of us aren’t very good at communicating how much we’re suffering.

Not only are we bad about communicating it, but research also shows that most of us are not as good at reading others’ emotions as we think we are. (In fact, some studies indicate the better we think we are at reading emotions in others, the worse we actually measure for the skill.1 !)

Image of the heads of three doodled people. The furthest left has dark skin, dark wavy hair with a pink stripe, and a surprised expression. The middle person has light skin, freckles, orange hair, glasses, and a content expression. The person furthest to the right has dark skin, tight, curly hair, and an unsure expression.

SUDS: A Language for Communicating Clearly about Emotional Pain

The Subjective Units of Distress Scale (SUDS) was developed by Joseph Wolpe in 1969 as a solution to this common communication problem.

The SUDS scale usually involves simply asking people to rate discomfort from 1-10. About a year ago, I began to artistically play with the idea of adapting the Subjective Units of Distress scale for visual thinkers.

Researchers learned while developing the FACES® Pain Rating Scale (you probably remember if from your last visit to an ER) that looking at faces to empathize with when we are suffering can help us think more clearly about the level of distress we are experiencing. Picking a face, stating the matching number, or even just pointing can be a powerful way to self-advocate and clearly communicate our level of suffering to others.

Download this Distress Scale PDF

This download offers two versions: a one-page download including the PDF pictured above and a Pro-Pack, which includes the pictured PDF, a black and white version of the PDF, and a version with a white background.

A Basic Introduction to the SUDS scale:

The SUD scale – or the Subjective Units of Distress Scale – is a way to measure how someone is feeling inside. It has previously been used in medical offices and has now become a tool used by therapists.

SUDS offers a way to tell our provider just how bad our emotional pain or discomfort is. By communicating this clearly, in number form, we can help providers help us more effectively.

Through an invitation to rate our distress or discomfort on a scale of 0-10, a mental health professional can get a better understanding of how much we’re struggling. Because it’s in the context of a scale, reporting an “8” can provide more helpful information than a statement like “I’m really struggling right now.”

This scale- and my visual version – can be used to measure a wide range of different types of distress- like emotional distress, anxiety, or worry – and it can help a provider customize care to each person.

When used over time, this scale can also be used to figure out how well a treatment is working for a person.

Image of three doodled people. Person on the left has brown curly hair, dark skin, glasses, and a sad expression. The person in the middle has long, straight blue-purple ombre hair, light skin, and a happy expression. The person on the right has a dark brown tight afro, dark skin, and wide eyes accompanying a shocked expression.

How the SUD Scale Helps People Communicate

SUD scales are meant to help people talk about their internal experiences, which helps other people understand what we’re going through. It can also help us understand ourselves better. When we identify and understand our own internal experience, we fuel self-growth.

How A Visual SUDS Scale May Be Helpful

My visually formatted SUD scale is a helpful way to communicate internal feelings because it gives both sides a starting point for understanding. Scales like the SUDS help providers and patients speak the same language when they talk about internal experiences. People who are in therapy can use these scales to see how things are going. They can also use them to help them understand and identify their own experiences. Through the use of SUD scales, providers and patients can build a relationship built on trust and clear communication.

Three hand drawn people. Person on the left has straight black hair with bangs, medium skin tone, and a worried expression. Person in the middle has short grey hair, turquoise earrings, light skin, and a displeased expression. Person on the right has straight blonde hair, light skin, and is grimacing/crying.

Why Medical Providers Shifted from A “Rate Your Pain on 1-10” SUD Scale to A “Which Face-in-Pain Do You Identify With?” Scale

The reason for using faces in addition to numbers within the SUD scale is that it is easier to understand.

Numbers can be challenging to conceptualize for some brains, and for some people, using numbers in counseling sessions feels clinical and pathologizing (aka, their detached coldness can make us feel like we’re sicker than we are)

Faces, on the other hand, are very real. A face that looks calm and relaxed is very different from a face that looks scared and panicked, and our brains are designed to tell the difference right away. This is especially true for children, who may not yet have a firm understanding of numbers. Using faces to represent different levels of anxiety can help people better understand and put into context how bad their anxiety, pain, or distress is.2

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The subjective units of discomfort scale is especially helpful for therapists who work with clients with specific phobias or anxieties. It can also be helpful in classrooms and even personal relationships to help create a language in which people can effectively communicate just how distressed they are.

One of the problems with communicating about mental distress or emotional pain is that it’s really hard! While we all think we’re pretty good at reading another person’s emotional state, the truth is that all of us process and express distress differently:

  • Individuals who grew up in a home with a lot of intergenerational trauma, where emotions were not safe to display, may not show a lot of emotion when upset.
  • On the other hand, kids who grew up in families where the only way to get needs met was through dramatic attention-seeking behavior may demonstrate more visible signs of emotional distress when, actually, they’re coping okay.

Because of this wide variance in the ways that we express emotion – and an equally broad range of abilities to intuitively know what another person is feeling – precise communication can be important.

Using a subjective units of discomfort (SUD) scale in therapy, a classroom, or even around the dinner table at home is a way to care for ourselves and others by creating a language that precisely communicates to others how are doing.

While some people begin to cry at a “2” on the SUD scale, for others, tears might not come until eight or even not at all. If we were to make an assessment of someone’s emotional distress entirely based upon our expectation of when tears should appear, we’d risk damaging a relationship.

How to Use the SUD Scale

At Home

Post the SUD scale on your refrigerator or in another prominent place in your home. (Perhaps, next to a filled-out crisis plan for every family member, so you know what kind of care each other needs when you hit a “6” or “7” of feeling really bad.)

When you find yourself in difficult conversations, emotionally-charged exchanges, or conflicts, check-in with each other. Before making assumptions about the other person’s emotional state, ask, “Where are you on the SUD scale right now?” Checking-in in this way can give you better information about whether to pursue the conversation or to take a break and get some care.

In the Classroom

Every good classroom challenges students – but, as any good teacher knows, if students are too overwhelmed, very little learning can occur. To use the SUD scale in a classroom, introduce your students to the scale and talk them through each of the levels. After introducing the tool, post it visibly in your classroom. When a student – or an entire class, collectively – seems to be struggling, check-in and ask where they’d rate themselves on the SUD scale.

In Therapy and Other Helping Professions

Like a great teacher, the job of therapists and other helping professionals is to help people grow without overwhelming them- that’s the basics of the concept of Window of Tolerance. People grow at their own pace and can tolerate only as much as they can tolerate on any given day. While therapists are often especially empathic and may even pride themselves on the ability to read another person’s emotion, the SUD scale can be an invaluable tool to use as a part of psychotherapy.

Therapists who practice exposure therapy, work with phobias, or counsel clients through specific anxieties may benefit from giving clients an empowering way to very clearly communicate when they are ready for us to press in, pause, or back off.

  1. Ames, D. R., & Kammrath, L. K. (2004). Mind-reading and metacognition: Narcissism, not actual competence, predicts self-estimated abilityJournal of Nonverbal Behavior28(3), 187-209. []
  2. Luber, M. (Ed.). (2015). EMDR therapy and emergency response. Springer Publishing Company: NY. []

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