“On a scale of 0-10, how would you rate your pain today, Jamie?,” she asked.
“You know I really hate that question,” I replied.
“I know, I know, but if you had to average it?,” she persisted.
No, this was not an exchange between my EMDR Therapist and I, although a similar conversation could indeed be had around the Subjective Units of Distress (SUDs) scale. This conversation was with my physical therapist. Due to a recent injury, I’ve been taking part in regular, body saving physical therapy sessions that have tremendously benefitted me and improved my quality of life. And at the beginning and end of each session, I get the “How would you rate your pain?” question.
“Here’s why I hate the question,” I told her, “Right now, standing in the warm water talking to you, it’s a 1. Getting out of bed this morning it was 4. But if I were to jolt suddenly in one direction or run into a shelf at the store, which has been happening because the nerve damage in my feet can make it hard to negotiate corners, it’s up at an 8 again.”
“So we can average it at a 4?,” she asked, very clearly needing to punch something quantitative into her computer.
“No,” I said, “That’s not a fair assessment… but put in what you have to for insurance, I guess.”
With a sigh, I wondered if we as EMDR therapists sound that annoying when we take SUDs scale ratings in the delivery of the EMDR Therapy protocol? Very likely yes, especially for therapy participants who know that a simple number measurement can never fully describe the complexity of human pain.
The medical field, in my experience, has a difficult time handling complexity or working with phenomena that cannot be easily explained in numbers or by the laws of science. While I appreciate the need for empirical research, I am often skeptical of it because I know that numbers and scales cannot fully capture nuance. In our push for widespread credibility, it saddens me that therapeutic models like EMDR Therapy and its various spinoffs have taken a similar view. The early work that EMDR founder Dr. Francine Shapiro had to do to get EMDR Therapy more widely recognized required her to come up with scales that are measurable. While I respect this work, it saddens me that in clinical practice it can translate into the people we serve stumbling over scales when the description of their pain and their response to interventions may be better expressed through words and concepts. In other words, qualitatively.
I am not totally dismissing the utility of numerical scales in EMDR or in any other therapeutic form. Some people are better able to put things into numbers. What I want us to be, as EMDR providers, is more adaptive to different learning styles. Yet the predicament still remains in EMDR that some people with complex trauma or dissociative responses may never get a SUDs rating down to a 0 in processing a memory. Of course we have our standard lines that we tell people: (a) it can be an “ecological” zero if a 1 or a 2 is the closest it will come and there are good reasons for it not moving down, or (b) “zero” can mean “neutral,” it doesn’t have to fully mean no distress. Yet many people I’ve served over the years can call out the bullshit in these lines too.
However, many folks we serve are able to tell us with behavioral descriptions how their responses and ultimately their lives are improving as a result of doing EMDR Therapy, regardless of what the numbers say. Shouldn’t this matter? My argument is that you can write up your progress or service notes with behavioral language changes or using descriptions of how emotional responses have changed when a memory comes up, whether or not you can put a number on it. If you absolutely have to put some kind of number on it for insurance or third party payers, like my physical therapists no doubt had to do, I would say, hesitantly, to do what you must. Yet in interacting with our therapy participants, honor their reports that movement and even progress can be measured in more ways than numerically.
