Question 1

Can you explain what the "Unified Protocol for the transdiagnostic treatment of emotional disorders" actually refers to for someone new to the topic?

David Barlow · Accepted Answer

The UP is a psychological treatment consisting of five “core” modules or components based on CBT elements of proven effectiveness that target temperamental characteristics, particularly neuroticism and resulting emotion dysregulation, underlying all anxiety, depressive, and related disorders. By addressing shared mechanisms, the UP can be used to treat a wide range of mental health problems with a single protocol.

Question 2

What are the core treatment components of the Unified Protocol?

David Barlow · Accepted Answer

The UP consists of five core treatment components. The first core component focuses on increasing mindful emotion awareness through emphasizing present-focused and non-judgmental awareness of emotional experiences. The second introduces the practice of cognitive flexibility through an overview of common negative automatic thought patterns that are associated with different emotions and practices to help promote more flexible appraisals. The third core component focuses on identifying and preventing behavioral and emotional avoidance of emotion-provoking stimuli. Finally, the final two core components of the UP involves both interoceptive and situational exposures to intense negative emotions triggered by emotion-eliciting stimuli and situations.

In addition to these core components, the UP includes exercises designed to build motivation to engage in treatment, a psychoeducation module that helps clients appreciate the function of different emotions and provides skills to monitor emotional experiences, and a relapse prevention module at the end of the program.

Question 3

Dear David,
Despite the growing significance of transdiagnostic approaches, in your experience, what drawbacks & challenges have you learnt about transdiagnostic approaches?

David Barlow · Accepted Answer

The underlying theoretical premises of treating temperament need more extensive evaluation, although preliminary analyses are promising (Sauer-Zavala et.al., 2020). Also, we are challenged with the issue of where to draw the line on additional content and the extent to which variations of the protocol are needed. In recent years, we have seen a number of adaptations of the UP for specific clinical presentations. We believe that it is important to provide clinicians with guidance on how the UP can be applied to different psychological and behavioral health conditions. This was the purpose of our Applications book. However, in general, we have been reluctant to alter the primary core components of the protocol. Having different UP-based treatments for specific problems would defeat the purpose of a single transdiagnostic protocol. As the same time, we don’t want to exclude content that could improve efficacy or make the protocol more acceptable. For example, in treating emotional disorders, there is a growing body of research to suggest that it may be important to focus on positive emotions (and goal- or reward-seeking behaviors) in addition to negative emotions. Currently, the UP more directly targets the propensity to experience negative emotions. However, we are currently conducting a clinical trial (supported by the John Templeton Foundation) to examine the efficacy of adding positive-affect focused components to the UP. We are excited to see the results!

Craske, M. G., Meuret, A. E., Ritz, T., Treanor, M., Dour, H., & Rosenfield, D. (2019). Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia. Journal of Consulting and Clinical Psychology, 87(5), 457–471. https://doi.org/10.1037/ccp0000396

Sauer-Zavala, S., Fournier, J. C., Steele, S. J., Woods, B. K., Wang, M., Farchione, T. J., & Barlow, D. H. (2020). Does the unified protocol really change neuroticism? Results from a randomized trial. Psychological Medicine, 1–10. https://doi.org/10.1017/s0033291720000975

Question 4

What are the differences and similarities between UP and ACT approaches? How do the 5 core processes of UP compare to the 6 core processes of ACT? Both appear to use mindfulness, addressing experiential avoidance, and a willingness to experience discomfort. Thank you

David Barlow · Accepted Answer

Consideration of similarities and differences between the Unified Protocol (UP) and ACT provides for some interesting conceptual distinctions that may be heuristic for the field. We have addressed some of these distinctions in reviewing various conceptions and definitions of "transdiagnostic treatments" which could describe both approaches (Sauer-Zavala, Gutner, Farchione, Boettcher, Bullis, & Barlow, 2017). ACT basically falls under the heading of a universally applied set of therapeutic principles that emerges from theory or, in years past, a "school" of psychotherapy describing components of intervention generally applicable to all (or almost all) presenting problems, something we call a "top-down" approach. Other examples would be psychodynamic psychotherapy, or person centered therapy, although clearly and unlike those examples ACT has substantial empirical support. The UP, on the other hand is derived directly from the recent identification of shared mechanisms of psychopathology common to a class of disorders, in this case the emotional disorders. Elsewhere, we have described what constitutes an "emotional disorder" (Bullis, Boettcher, Sauer-Zavala, Farchione, & Barlow, 2019). This could be called a "bottom up" approach where the putative functional relationships common to all emotional disorders become the therapeutic target. In so doing we stipulate that we are addressing the temperament of neuroticism itself using well-established psychological and neurobiological principles of extinction, and that the UP would only be applicable to disorders lying along the so-called neurotic spectrum.

That said, ACT and the UP do contain similar procedures along with the marked conceptual differences in the approaches which is not surprising given that both are characterized as fundamentally cognitive behavioral interventions. It is also the case that the UP, along with ACT and some other so-called " third wave" approaches fit comfortably within what Hayes and Hofmann call "process based therapy" emphasizing an individual analysis of functional relationships in a given individual (see Hoffman & Aderka, in press).

Bullis, J., Boettcher, H., Sauer-Zavala, S., Farchione, T. J., & Barlow, D. H. (2019). What is an emotional disorder?: A transdiagnostic mechanistic definition with implications for assessment, treatment, and prevention. Clinical Psychology Science and Practice, 26, 2.

Hoffman. S., & Aderka, I. M. (in press). Social anxiety: A process-based approach. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (6th ed.). New York, NY: The Guilford Press.

Sauer-Zavala, S., Gutner, C. A., Farchione, T. J., Boettcher, H. T., Bullis, J. R., & Barlow, D. H. (2017). Current Definitions of “Transdiagnostic” in Treatment Development: A Search for Consensus. Behavior Therapy, 48(1), 128-138.

Question 5

Is there room in the UP for an individualized case conceptualization approach? How does a universal treatment like the UP address the need for case conceptualization based on individual maintaining factors?

David Barlow · Accepted Answer

Case conceptualization using the UP focuses on a client’s relationship with their emotions—that is, how they experience, process, and respond to strong emotions. Each element of the UP is meant to alter some aspect of maladaptive emotion processing (e.g., cognitive inflexibility, experiential avoidance). Thus, the UP operates on a higher-order level than interventions that directly target disorder-specific psychological symptoms. Given this broad framework, the UP necessitates individualized conceptualization that acknowledges crucial individual differences in emotional processing that maintain psychopathology.

As a foundation for conceptualizing individual cases, we recommend conducting a functional assessment with clients in order to understand how they respond to strong emotions. The functional assessment is meant to assess the features of an emotional disorder: experiencing negative emotions frequently and/or intensely; judging negative emotions as aversive, unwanted, or intolerable; and engaging in avoidant coping strategies that function to reduce emotional intensity in the short-term. This framework allows for an exploration of individual differences in emotional processing that is not bound by diagnostic categories. For example, clients who meet criteria for a particular disorder may still struggle with emotions outside of DSM criteria (e.g., anxiety in major depressive disorder, anger in panic disorder). Furthermore, the UP emphasizes understanding the function of maladaptive behaviors in order to apply treatment strategies most effectively. For example, clients who meet criteria for comorbid diagnoses may not understand how different behaviors may serve the same avoidant function (e.g., compulsive checking in OCD and excessive reassurance-seeking in GAD may both serve as mechanisms to avoid guilt). Conversely, the same behavior may serve different functions based on context (e.g., a client with social anxiety and depression may avoid social interactions due to worries about being judged by others or due to worries of not enjoying oneself sufficiently).

The functional assessment is typically conducted in the first session of the UP. The therapist guide contains useful tips for conducting this assessment (Barlow et al., 2017). Furthermore, Boettcher & Conklin (2017) have described a case conceptualization tool that was developed to assist in understanding individual maintaining factors and how they can be addressed in the UP.

Barlow, D. H., Farchione, T. J., Sauer-Zavala, S., Latin, H. M., Ellard, K. K., Bullis, J. R., ... & Cassiello-Robbins, C. (2017). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. Oxford University Press.

Boettcher, H., & Conklin, L. R. (2017). Transdiagnostic assessment and case formulation: Rationale and application with the Unified Protocol. In D. H. Barlow & T. J. Farchione (Eds.), Applications of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (pp. 67-85). Oxford University Press New York, NY.

Question 6

Question 7

Given it's focus on emotion regulation, how is the UP similar/different to DBT?

David Barlow · Accepted Answer

This is an interesting question that speaks to the progression of psychotherapy research. Dialectical behavior therapy (DBT) is a sophisticated complex treatment originally designed specifically to treat one of the most difficult and demanding disorders confronted by therapists, borderline personality disorder (BPD). But part of the genius of Marsha Linehan who originated the intervention was that in addition to addressing severely distorted interpersonal relations, the hallmark of a personality disorder, she incorporated elements of affect regulation. The Unified Protocol (UP) on the other hand originated from early attempts to treat panic disorder in the 1980s. Since both treatments are fundamentally cognitive behavioral in nature it is not surprising that the affect regulation components of DBT have some similarities to components in the UP despite their very different origins. Also, we have come to conceptualize BPD as fundamentally an emotional disorder rather than a personality disorder (Sauer-Zavala and Barlow 2014) and have published articles on treating BPD with the UP (e.g. Sauer-Zavala, Bentley, & Wilner 2016; Sauer-Zavala, Bentley & Wilner, 2019). More recently DBT has also come to be recognized as capable of transdiagnostic applications (e.g. Neacsiu, Zerubavel, Nylocks, & Linehan, in press). In a collaborative project several years ago Sauer-Zavala, Barlow, and Linehan surmised that the UP was most likely to be effective with the 75% or so on the less severe end of the severity spectrum of BPD, while those with the most severe presentations would seem to require the full application of DBT. This assumption requires confirmation.

Neacsiu, A.D., Zerubavel, M. Nylocks, K.M., & Linehan M. M. (in press) Borderline Personality Disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (6th ed.). New York, NY: The Guilford Press.

Sauer-Zavala, S. & Barlow, D.H. (2014). The case for borderline personality disorder as an emotional disorder: Implications for treatment. Clinical Psychology: Science and Practice, 21(2), 118-138.
Sauer-Zavala, S., Bentley, K.H., & Wilner, J. G. (2016). Transdiagnostic treatment of Borderline Personality Disorder and comorbid disorders: A clinical replication series. Journal of Personality Disorders, 30(1), 35-51.

Sauer-Zavala, S., Bentley, K.H., & Wilner, J. G. (2019). Conceptualizing Borderline Personality Disorder within an emotional disorders framework: Implications for treatment with the Unified Protocol. In U. Kramer (Ed.), Case formulation for personality disorders.Cambridge, Massachusetts: Academic Press.

Question 8

Question 9

How do you assess whether your client's experience fits with a transdiagnostic model like the UP?

David Barlow · Accepted Answer

Prior to beginning treatment, we recommend that clinicians identify whether a client experiences or exhibits characteristics of what we have described as an “emotional disorder” (Bullis et al., 2019); namely, frequent and intense negative emotions (i.e., neuroticism), negative reactions to these emotions, and a tendency to avoid or suppress them (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014). This can be done without a formal diagnostic evaluation. However, diagnosis often provides clinicians with nomothetic information that can help orient them to a more specific individualized formulation. For example, a client with generalized anxiety disorder is likely to engage in reassurance seeking behaviors to avoid feelings of anxiety related to perceived negative outcomes. Examples of the types of emotions, reactions, and avoidance observed in emotional disorders, as well as detailed discussion of assessment and transdiagnostic case conceptualization are provided in our Applications book (e.g., Boettcher & Conklin, 2018).

Barlow, D.H., Sauer-Zavala, S., Carl, J.R., Bullis, J.R., & Ellard, K.K. (2014). The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344-365.

Boettcher, H., & Conklin, L.R. (2018). Transdiagnostic assessment and case formulation: Rationale and application with the Unified Protocol. In D.H. Barlow & T.J. Farchione (Eds.) Applications of the Unified Protocol for transdiagnostic treatment of emotional disorders (pp. 17-37). Oxford University Press: New York.

Bullis, J. R., Boettcher, H., Sauer‐Zavala, S., Farchione, T. J., & Barlow, D. H. (2019). What is an emotional disorder? A transdiagnostic mechanistic definition with implications for assessment, treatment, and prevention. Clinical Psychology: Science and Practice, 26(2), e12278.

Question 10

Has the Unified Protocol been used for Borderline Personality Disorder related problems?

David Barlow · Accepted Answer

Yes it has! In fact, the ability of the UP to target emotion dysregulation is well suited for treating Borderline Personality Disorder (BPD), which has been characterized as a disorder of emotion (Linehan, 1987). There have been a number of preliminary studies looking at the efficacy of the UP for BPD (Lopez et al., 2015; Sauer-Zavala, Bentley, & Wilner, 2016). UP modules have also successfully been applied to high-risk behaviors that are often associated with BPD, such as non-suicidal self-injury and suicidal thoughts/behaviors (Bentley, 2017; Bentley et al., 2017a; 2017b). Additional clinical trials are needed to replicate these findings; however, these results are certainly encouraging.

Bentley, K. H. (2017). Applying the Unified Protocol Transdiagnostic Treatment to Nonsuicidal Self‐Injury and Co‐Occurring Emotional Disorders: A Case Illustration. Journal of clinical psychology, 73(5), 547-558.

Bentley, K. H., Nock, M. K., Sauer-Zavala, S., Gorman, B. S., & Barlow, D. H. (2017a). A functional analysis of two transdiagnostic, emotion-focused interventions on nonsuicidal self-injury. Journal of consulting and clinical psychology, 85(6), 632.

Bentley, K. H., Sauer-Zavala, S., Cassiello-Robbins, C. F., Conklin, L. R., Vento, S., & Homer, D. (2017b). Treating suicidal thoughts and behaviors within an emotional disorders framework: Acceptability and feasibility of the unified protocol in an inpatient setting. Behavior modification, 41(4), 529-557.

Linehan, M. M. (1987). Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Personality disorders, 1(4), 328-333.

Lopez, M. E., Stoddard, J. A., Noorollah, A., Zerbi, G., Payne, L. A., Hitchcock, C. A., ... & Ray, D. B. (2015). Examining the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders in the treatment of individuals with borderline personality disorder. Cognitive and Behavioral Practice, 22(4), 522-533.

Sauer-Zavala, S., Bentley, K. H., & Wilner, J. G. (2016). Transdiagnostic treatment of borderline personality disorder and comorbid disorders: A clinical replication series. Journal of personality disorders, 30(1), 35-51.

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