How SUD and VOC Scales Work Together in EMDR

The validity of the cognition (VOC) and subjective units of disturbance (SUD) scales serves as navigational tools to help therapists track progress throughout EMDR therapy.

SUD measures the intensity of disturbance the memory still causes, while VOC shows how adaptively and strongly the positive belief has been integrated.

For example, you were involved in a car accident 5 years ago. You already know the event is over, but thinking about it may still trigger a racing heart and rapid breathing. These reactions would be reflected in a higher SUD score. As EMDR therapy progresses, emotional distress decreases, resulting in lower SUD scores.

A study in 2022 suggests that successful EMDR is often associated with higher VOC scores and lower SUD scores. Higher VOC ratings indicate that positive beliefs feel more believable to the client.

The therapist uses both scales throughout EMDR treatment and monitors emotional shifts, evaluating progress during the EMDR session.

Why Therapists Measure SUDs and VOCs in EMDR

VOC and SUD provide valuable insight into psychological intensity. Both scales provide a snapshot of a client’s growing belief. 

VOC and SUD allow the therapist to:

1. Track emotional changes over time
2. Monitor the strength of positive cognition
3. Assess treatment effectiveness
4. Determines whether additional processing may be needed
5. Personalized treatment based on individual progress

As therapy progresses, research suggests that SUD decreases while VOC scores increase. This reflects reduced emotional disturbance and stronger acceptance of positive beliefs. 

SUD and VOC EMDR are not just measuring tools; instead, both provide a clear picture of EMDR treatment progress and valuable insight.

5 Practical Tips for Measuring SUDs and VOCs in EMDR Sessions

Here are 5 practical tips for measuring SUD and VOC in EMDR therapy sessions.

1. Clearly Explain Both Scales and Use Consistent Language

Take time to explain the purpose of both the VOC and the SUD scales during phase 2 (preparation). Introduce each scale and how its rating will be used throughout EMDR treatment. The goal is not to achieve particular scores, but to understand the client’s self-cognition and emotional experience as accurately as possible.

For example, a 6 may feel like a massive crisis to some, but slightly uncomfortable to others. People may interpret the scale differently if not explained properly. To optimize therapy, it is crucial to explain both scales clearly.

Use standardized phrasing because consistency builds the client’s confidence.

2. Ask Questions That Focus on Emotional Experience

Assess their emotional response rather than intellectualizing their feelings. This involves asking them questions that focus on how they feel, rather than what they think they should feel, or what would be right to feel in their opinion.

A client may intellectually feel “they are safe,” but lower VOC scores indicate their brain still feels the trauma. True integration occurs when emotional experiences align with the rational truth, resulting in VOC scores of 6 or 7.

The wording used when assessing VOC can significantly influence how accurately clients rate their feelings and experiences. 

Remember, this is about the client’s feelings associated with the scales, not thinking.

3. Track Changes Throughout Every Session 

Record SUD and VOC ratings fluctuations. With regular EMDR therapy sessions, there may be times when the client’s scale scores show a sharp dip or rise in the SUD scale. This is completely normal, as the therapy is still in progress, and the process of unraveling trauma comes with highs and lows.

The most common misconception among new EMDR clients is that SUD scores should decrease steadily. It is not the case; it may fluctuate across sessions. The therapist records the arc over the entire therapy session, not just moment-to-moment numbers.

4. Recognize that SUD and VOC Changes at Different Paces

SUD and VOC measure different aspects of recovery and are used in different phases of the EMDR therapy. SUD is mainly used to measure emotional disturbance. Therapists use it in Phase 3 (Assessment) and Phase 4 (Desensitization) to track whether the memory is becoming less painful and upsetting.

On the other hand, VOC measures positive cognition, and therapists use it in Phases 3 (Assessment) and 5 (installation) after distress has decreased and the client is ready to strengthen the positive belief.

5. SUD and VOC scores do not always change or improve at the same rate

When the client rates at SUD or VOC, make sure the client is focusing on the same targeted memory each time the scores are measured. Consistent measurement benefits the therapist in identifying meaningful changes and evaluating the treatment process more effectively.

6. Adapt VOC and SUD Scales for Cultural Nuance and Client Capacity

The SUD and VOC are numerical tools; not every client relates easily to the numerical ratings. Both scales are not just numbers but provide a baseline and help the therapist to compare progress throughout EMDR treatment.

For example, numerical scales can be too abstract for children to correlate with emotion, and some people may not be able to understand and express the intensity of their response. In the same vein, people who experience symptoms of dissociation or have DID may feel numb because of dissociation while actively suffering unconsciously. In such instances, it is ideal to observe the client’s physical response and behavior and correlate with their scale scores to cross-check.