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DBT skills work. They can help someone navigate difficult conversations, extreme dysregulation, suicidal ideation – really a wide variety of symptoms that come along with the diagnosis that bring people into treatment. Once over-learned and practiced, individuals can avoid the behaviors that have made things worse (ie. yelling at a friend or family member, cutting, using substances) and instead participate fully in life, with eyes wide open, creating their “life worth living.” 

But when does one use which skill? The answer to this question is as important as the skills themselves. The SUDS scale is a way to mindfully check-in with one’s current level of distress and inform one in what skills would be most appropriate to use at any given time.

What is the SUDS (Subjective Units of Distress) scale?

The SUDS scale is a brief self-report measure of distress tolerance developed by Linehan and colleagues (1999), with individuals identifying their subjective intensity of current distress on a scale from 0 to 10 (0 = no distress, 10 = maximum distress). Precision on this scale is not of utmost importance, as its utility in part comes from its brevity and simplicity. One can define the scale subjectively, as long as the book ends are similar to “at peace and as calm as one can be” as a 0 to “as dysregulated or upset as one could imagine” as a 10.

SUDS: A scale to use every day

Most scales (such as the PHQ-9,  GAD-7 and Columbia Risk Assessment Engage Therapy uses) serve to assist mental health professionals in diagnosis, assessment, to inform and shape treatment, and to measure the outcomes of interventions. The SUDS scale is different: it is a tool foundational in DBT for individuals themselves to consistently use in everyday life. When one has more awareness of their emotional dysregulation, one can be more informed as to what they need to do to participate fully in life and live a life worth living.  an individual can learn to identify what DBT skills work best for them, and when, as well as 

SUDS and the three categories of DBT skills: Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance

Dialectical Behavior Therapy, alongside other models of therapy, teaches a wide range of skills. As an example, one of the popular skills is DEAR MAN – an interpersonal effectiveness skill – which can guide one on most skillfully getting what you need from relationships while respecting yourself and others, with the least likelihood of eliciting a defensive stance or response in the other. 

However, DBT also teaches that you are extremely unlikely to be successful at accessing the acronym and complex narrative structure of DEAR MAN when you are “at a 10.” This would be a  time where your limbic brain and your built-for-survival fight or flight response is “running the show” and your prefrontal cortex, the part of your brain that allows humans to make complex decisions and think analytically, is much less in control. That is to say, attempting to engage in discussion “at a 10” is more likely to “make things worse.”  For this reason, DBT outlines three major categories of skills that are attached to the to use within the SUD scale. If one identifies they are “at a 10,” then using distress tolerance skills – note TOLERATE, not MAKE BETTER – the individual can have the time necessary for the body and mind to do what it will do naturally – regulate. This buffer of time is what can be necessary to move down the scale to “a 5,” use an emotion regulation skill to then help that person move down to “a 2” – NOW is the time one can access and skillfully use DEAR MAN.

0-3:  Interpersonal Effectiveness Skills

  • DEAR MAN
  • GIVE
  • FAST
  • Interpersonal Myths
  • Cheerleading Statements
  • Validation

4-6: Emotion Regulation Skills

  • ABC PLEASE
  • Build Positive Experiences
  • Ride the Wave
  • Identifying and Describing Emotions
  • Opposite Action
  • Pleasant Activities List
  • Letting Go of Painful Emotions

7-10: Distress Tolerance Skills

  • TIPP: Changing Body Chemistry
  • ACCEPTS
  • IMPROVE
  • Pros and Cons
  • Radical Acceptance and Turning the Mind
  • Willingness and Half Smile
  • Alternate Rebellion
  • Self-Soothe with the 5 Senses

In conclusion, the SUDS scale is an important tool in Dialectical Behavior Therapy for individuals to use every day. The SUDS scale can help individuals identify which category of DBT skills to use (interpersonal effectiveness, emotional regulation, or distress tolerance) at a given moment.

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