Question 1

Can you explain what the "Unified Protocol for the transdiagnostic treatment of emotional disorders" is 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 emotional disorders?

David Barlow · Accepted Answer

The following criteria have been proposed to define or characterize an emotional disorder: (1) frequent and intense negative emotions, (2) negative reactions to these emotions, and  (3) attempts to reduce, escape, or avoid them.

(Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014).

Anxiety and depressive disorders, as well as other conditions that share these characteristics, such as borderline personality disorder and post-traumatic stress disorder, could be grouped under this heading (Bullis et al., 2019). The experience of frequent and intense negative emotions has been conceptualized in the literature as a personality or temperament style (e.g., neuroticism) that predisposes individuals to experience negative emotions more frequently and intensely than those without this temperamental predisposition. Negative reactions to these emotional experiences are often characterized by appraisals of emotions as being uncontrollable and unpredictable. These interpretations result in decreased acceptance of, and willingness to tolerate, emotional experiences which then manifests behaviourally through explicit and implicit efforts to suppress or avoid emotional experiences. These forms of avoidance contribute to the maintenance of negative emotional states over time. This proposed definition of an emotional disorder serves the function of identifying several transdiagnostic mechanisms that underlie clinical phenotypes and can serve as targets for interventions. For additional information about the definition and conceptualization of emotional disorders and implications for assessment and treatment, please see Bullis et al., 2019.

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.

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 3

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 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

Are transdiagnostic treatments as effective as disorder-specific treatments?

David Barlow · Accepted Answer

This is an important question that our research group recently examined. To determine the Unified Protocol’s (UP) equivalency to single-diagnosis protocols (SDP’s), we ran a large randomized control trial testing the UP’s efficacy against gold-standard SDP’s for four different anxiety disorders (Barlow et al., 2017). In our sample of 223 patients, the UP was found to be as effective as the SDP’s for treating panic disorder, general anxiety disorder, obsessive-compulsive disorder and social anxiety disorder. These improvements held through a 12-month follow-up period. In addition, there was significantly less dropout in the UP condition compared to the diagnosis-specific protocols, suggesting that the UP may offer benefits with regard to attrition.

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial. JAMA psychiatry, 74(9), 875–884.

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

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 9

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.

Question 10

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 11

How does the Unified Protocol model understand and conceptualise comorbidity? What are the shared underlying mechanisms that you propose to be present in anxiety and depressive disorders?

David Barlow · Accepted Answer

For us, the co-occurrence of emotional disorders (i.e., anxiety, depressive, and related disorders) simply reflects core temperamental characteristics and shared underlying psychopathological processes that contribute to the development and maintenance of these disorders. How this manifests at the symptom level, of course, differs from person to person. But all emotional disorders (i.e., anxiety, depressive, and related disorders) can be characterized by: 1) frequent and intense negative emotions, 2) negative reactions to these emotions, and 3) subsequent attempts to decrease or avoid these emotions. For further discussion on emotional disorders please see Bullis and colleagues’ recent article (2019).

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 12

Has the Unified Protocol been used with children and adolescents?

David Barlow · Accepted Answer

The Unified Protocol has indeed been used with children and adolescents! Due to the high comorbidity rates of anxiety and emotional disorders, particularly in adolescents, a transdiagnostic approach creates an excellent opportunity for well-rounded early intervention and empirically based treatment. Both a therapist guide and client workbooks have been published with the specific focus of treating children (UP-C) and adolescents (UP-A; Ehrenreich-May et al, 2018a, 2018b, 2018c). The therapist guide includes individual therapy for adolescents as well as more structured group therapy for children. It contains a full parent curriculum and parent-focused handouts, while the workbooks contain worksheets, figures, and forms that are more youth-focused. The guide and workbooks have been altered from the standard UP to have more developmentally appropriate language and address some disorders less prominent in adulthood, such as separation anxiety disorder.
 
The UP-C teaches about the main components of treatment with a child-friendly theme of being a detective. The five core aspects of adult treatment become the sections that make up CLUES: “Consider how I feel,” “Look at my thoughts,” “Use detective thinking,” “Experience my fears and feelings,” and “Stay healthy and happy.”  The UP-C treatment most often consists of concurrent 60-minute parent and child sessions, and 30 minutes of joint parent-child treatment time. In a recent RCT (Kennedy, Bilek, & Ehrenreich-May, 2019), 47 children were randomized to receive either UP-C or an alternate anxiety control treatment. The results of the RCT indicated that the UP-C appears to be at least as efficacious as other established anxiety-focused group treatments for children, and that the UP-C may support better continued response to treatment at follow up. Similarly, a waitlist control trial of 51 adolescents focused on the UP-A (Ehrenreich-May et al., 2017), found that the treatment group had lower diagnostic severity and performed better than the waitlist condition, especially on clinical rated measures, at the 8-week timepoint. As with the UP-C, outcome measures also continued to improve after treatment. These data suggest that with proper age-appropriate adjustments, the UP is a suitable and efficacious treatment across all ages.

Ehrenreich-May, J., Kennedy, S. M., Sherman, J. A., Bilek, E. L., & Barlow, D. H. (2018a). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children: Workbook. Oxford University Press.

Ehrenreich-May, J., Kennedy, S. M., Sherman, J. A., Bennet, S. M.., & Barlow, D. H. (2018b). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents: Workbook. Oxford University Press.

Ehrenreich-May, J., Kennedy, S. M., Sherman, J. A., Bilek, E. L., Buzzella, B. A., Bennett, S. M., & Barlow, D. H.   (2018c). Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents: Therapist Guide. Oxford University Press.

Ehrenreich-May, J., Rosenfield, D., Queen, A. H., Kennedy, S. M., Remmes, C. S., & Barlow, D.H (2017).  An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents. Journal of Anxiety Disorders, 46, 46-55.

Kennedy, S. M., Bilek, E. L., & Ehrenreich-May, J. (2019). A randomized controlled pilot trial of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in children. Behavior Modification, 43(3), 330-360.

Question 13

Would you recommend the use of the Unified Protocol for a client with an eating disorder and obsessive-compulsive disorder?

David Barlow · Accepted Answer

There is growing support for application of the Unified Protocol with disordered eating presentations, including individuals with other co-occurring emotional disorders (see Boisseau & Boswell, 2018 for a brief review and application of the UP modules with a focus on eating disorders). In fact, in one recent major study the UP was adapted for group application for all patients in a national residential treatment center for severe eating disorders in the United States with evidence for efficacy over and above treatment as usual (Thompson-Brenner et al,. 2018). There is research evidence that both eating disorders and obsessive-compulsive disorder share similar emotional patterns – consistent with emotional disorders more broadly. Emotional disorders are characterized by frequent and intense negative emotions (i.e., neuroticism), negative reactions to these emotions, and a tendency toward attempts to avoid or suppress them (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014). To the extent that the conceptualization of emotional disorders is relevant and applicable to the client’s presentation, and a higher level of treatment (e.g., hospitalization) is not required, the UP may be appropriate.

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.
   
Boisseau, C.L., & Boswell, J.F. (2018). The Unified Protocol for eating disorders. In D.H. Barlow & T.J. Farchione (Eds.) Applications of the Unified Protocol for transdiagnostic treatment of emotional disorders (pp. 150-163). Oxford University Press: New York.

Thompson-Brenner, H., Brooks, G. E., Boswell, J. F., Espel-Huynh, H., Dore, R., Franklin, D. R., … Lowe, M. R. (2018). Evidence-based implementation practices applied to the intensive treatment of eating disorders: Summary of research and illustration of principles using a case example. Clinical Psychology: Science and Practice, 25(1). https://doi.org/10.1111/cpsp.12221

Question 14

I have been studying a lot about the Unified protocol. I would like to know what is your opinion on applying it in a group with 6 participants. I have checked that with 6 to 8 participants it could be applied.

David Barlow · Accepted Answer

We are frequently asked about the application of the UP in group settings, and for good reason. One of the benefits of the Unified Protocol is to reduce therapist burden by reducing the number of therapeutic manuals therapists need to specialize in as well as being able to address comorbid conditions simultaneously. In a similar vein, a natural second thought would be to utilize the protocol to reach as many patients as possible via groups (comorbid or not).

Although the UP was designed with both individual and group applications in mind, research has primarily focused on the individual format. Still, preliminary studies from our research team exist and demonstrate positive outcomes. In a pilot study by Bullis et al. (2015), a group of 11 diagnostically diverse patients underwent 12 weeks of the UP in group format. Findings suggest that the treatment resulted in moderate to strong effects on anxiety and depressive symptoms, functional impairment, quality of life, and emotion regulation skills. Further, patients reported good acceptability and satisfaction ratings of the treatment. Other group applications of the UP have been conducted abroad, as some healthcare systems often necessitate group formats.

Most notable is a recent trial conducted in Denmark on comorbid groups (7-9 patients each) presenting with principal anxiety in a mental health services clinic (Reinholt et al., 2017). Pre-post treatment measures demonstrated improvement consistent with research on the individual format of the UP. Further, researchers found that patients with higher levels of comorbidity benefited more than patients with less comorbidity. Of note, the UP has yet to be studied in group format with rolling admission, but it can be, and has been, done in clinical settings. For more information on group application, there is a dedicated chapter on this topic in “Applications of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders.”

Bullis , J.R., Bentley, K.H., & Kennedy, K.A. (2018). Group Applications of the Unified Protocol. In D.H. Barlow & T. J. Farchione (Eds.), Applications of the unified protocol for transdiagnostic treatment of emotional disorders. Oxford University Press.

Question 15

I typically struggle with tailoring the UP to depression, when depression symptoms are more at the forefront than anxiety. It appears that elements of behavioural activation, motivational tips, psychoeducation etc. are missing. Exposures are also more in line with anxiety. Can you help clarify?

David Barlow · Accepted Answer

Great question! In general, we conceptualize depression as one possible expression of neurotic temperament (i.e., frequent and intense negative emotions) and maladaptive coping. Because the UP focuses broadly on these underlying vulnerabilities, the motivation and psychoeducation modules look a little different than they do in disorder-specific protocols, but can certainly be applied effectively with patients who display a more depressive presentation. In module 1 (motivation enhancement), patients with depression may exhibit more ambivalence or hopelessness; we use a decisional balance exercise to openly discuss ambivalence and reinforce motivation to engage in treatment. We also set specific goals and break them down into smaller steps. Patients who express hopelessness about meeting their goals may feel more empowered when they are broken down into smaller steps. The goal-setting exercise also serves to provide some ideas for behavioral activation later in treatment.

In module 2 (psychoeducation), we validate and normalize the experience of negative emotions such as sadness, guilt, or anger by highlighting their adaptive nature. Knowing that emotions are valid and serve a purpose is a helpful jumping-off point for practicing the skills that come later in treatment. We also teach the three component model, which is similar to the CBT triangle and often yields disorder-specific content such as commonly-experienced cognitions (e.g., rumination, suicidal ideation), physical sensations (e.g., heaviness in limbs), and behaviors (e.g., social withdrawal, hypersomnia).

Behavioral activation is a crucial component of CBT for depression, and is sometimes delivered as a standalone treatment. In the UP, module 5 (countering emotional behaviors) is an opportunity to incorporate behavioral activation, framed as increasing activities that 1) run counter to emotion-related behavioral urges (e.g., social isolation in response to sadness, rumination in response to guilt) and 2) are associated with helpful long-term consequences. We encourage patients to review the goals they named in module 1 and consider whether they can take any steps toward those goals in the context of this module. Module 7 (emotion exposures) takes this further by providing a framework for systematically engaging in activities that uncomfortable or distressing emotions have made it difficult for them to engage in previously. In this way, emotion exposures with a depressed patient do not emphasize habituating to negative emotions, but instead emphasize practicing helpful responses to these emotions and disconfirming distorted predictions that might otherwise hold a patient back from engaging in effective, valued behavior.

Boswell, J. F., Conklin, L. R., Oswald, J. M., & Bugatti, M. (2017). The Unified Protocol for major depressive disorders. 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.

Farchione, T. J., Boswell, J. F., & Wilner, J. G. (2017). Behavioral Activation Strategies for Major Depression in Transdiagnostic Cognitive-Behavioral Therapy: An Evidence-Based Case Study. Psychotherapy, 54(3), 225-230. doi:10.1037/pst0000121

Sauer-Zavala, S., Bentley, K. H., Steele, S. J., Tirpak, J. W., Ametaj, A. A., Nauphal, M., ... & Barlow, D. H. (2020). Treating depressive disorders with the Unified Protocol: A preliminary randomized evaluation. Journal of Affective Disorders, 264, 438-445.

Question 16

Should we treat all co-occurring disorders with a single trans-diagnostic treatment protocol? Can you use the Unified Protocol when there are multiple co-morbid conditions including personality and substance use disorders?

David Barlow · Accepted Answer

The UP offers a single cognitive-behavioral intervention that targets underlying mechanisms common across emotional disorders (i.e., anxiety, depressive, and related disorders), and therefore can be applied to various disorders and symptom presentations. Of course, some patients may have other co-occurring disorders that are not emotional disorders, which may require additional treatment approaches (e.g., schizophrenia, ADHD, autism spectrum disorder).  
To date, some research has conceptualized Borderline Personality Disorder (BPD) as an emotional disorder (Sauer-Zavala & Barlow, 2014), and there is some preliminary support for the efficacy of the Unified Protocol for BPD (Sauer-Zavala, Bentley, & Wilner, 2016). With regard to substance use disorders, our group’s work to date has focused on individuals with co-occurring anxiety disorders and alcohol use disorder (AUD). There is some evidence that the UP may be helpful in reducing problematic alcohol use (Ciraulo et al., 2013). In fact, we are currently conducting a randomized clinical trial in our lab where we are comparing the UP to a psychoeducational intervention for adults with co-occurring anxiety disorders and alcohol use disorder (https://clinicaltrials.gov/ct2/show/NCT03230006). Within this study we conceptualize alcohol use as another way individuals may attempt to decrease or avoid their emotions. We look forward to sharing the results from this study once it is completed!

Ciraulo, D. A., Barlow, D. H., Gulliver, S. B., Farchione, T., Morissette, S. B., Kamholz, B. W., Eisenmenger, K., Brown, B., Devine, E., Brown, T. A., & Knapp, C. M. (2013). The effects of venlafaxine and cognitive behavioral therapy alone and combined in the treatment of co-morbid alcohol use-anxiety disorders. Behaviour research and therapy, 51(11), 729–735. https://doi.org/10.1016/j.brat.2013.08.003

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. https://doi.org/10.1111/cpsp.12063

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.

Question 17

Is a transdiagnostic approach used when diagnosis-specific treatment is impractical due to limited resources, or is it the treatment of choice in general?  Are there any studies of the approach in groups of individuals with chronic pain?

David Barlow · Accepted Answer

Utilizing the UP versus diagnosis-specific protocols is both practical and clinically beneficial. The UP can reduce burden on therapists and clinics by reducing training of multiple single-diagnosis protocols. Therapists and clinics can be burdened by the costs of attending trainings for a multitude of protocols to be able to deliver them to clients, as well as having to purchase the materials to do so. Further, after having learned all protocols, therapists then have to maintain that knowledge while some protocols may go unused for a period of time depending on client diagnostic presentations. As you can imagine, this can be particularly challenging in rural areas and clinics overwhelmed with patients and little funding.

The clinical benefits of the UP stem from the theoretical underpinnings of shared mechanisms across emotional disorders, namely neuroticism. Current and lifetime comorbidity rates are prevalent (consistently above 50%) for individuals presenting for treatment, and it can be challenging to either treat all at once with diagnosis-specific manuals or determine which disorders to prioritize first. The UP purports that it is likely that a patient’s presenting concerns (whether clinical or sub-threshold) are interrelated through a temperamental tendency to experience frequent negative emotions accompanied by negative reactions to these intense negative emotions. Interestingly, in a recent study, our research group discovered that at post-treatment, the UP did not significantly reduce concurrent comorbidities more than single-diagnosis protocols (Steele et al., 2018). On the one hand, this is unsurprising as the UP at its core is a cognitive behavioral treatment, as were the comparison single-diagnosis protocols, and includes traditional CBT skills; the primary difference is that the UP focuses more broadly on emotion, rather than provoking stimuli associated with each anxiety disorder (e.g., crowds in social anxiety). Long-term follow-up data from this study is currently being analyzed, but it is hypothesized that a broader focus of emotion may have long-term benefits for prevention of additional and related disorders that could arise. In other words, by using the UP, we may be increasing the generalizability of CBT skills to future concerns without having to necessarily re-enter therapy. As such, even in the less common case that an individual is only presenting with one disorder, the UP may have advantages over a single-diagnosis protocol. Lastly, a recent randomized control trial comparing the UP to leading single-diagnosis protocols found that the UP is at least equally efficacious at symptom reduction for a variety of disorders to these individual protocols targeting a single disorder (Barlow et al., 2017), suggesting that outcomes are not compromised by choosing the UP.

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial. JAMA psychiatry, 74(9), 875–884.

Steele, S. J., Farchione, T. J., Cassiello-Robbins, C., Ametaj, A., Sbi, S., Sauer-Zavala, S., & Barlow, D. H. (2018). Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders. Journal of Psychiatric Research, 104, 211–216.

Question 18

Given that sleep disturbance is highly comorbid with depression and anxiety, can insomnia be treated with the UP?

David Barlow · Accepted Answer

Insomnia is highly comorbid with depression and anxiety (Alvaro, Roberts, & Harris, 2013; Khurshid, 2018). In fact, there appears to be a bidirectional relationship between these conditions, such that insomnia contributes to depression and anxiety symptoms and these symptoms can lead to sleep disturbances as well.  Parallels between new models of insomnia and emotional disorders suggest they are influenced by similar cognitive and behavioural factors (Doos Ali Vand et al., 2018b).
Two studies have been conducted on the UP for insomnia disorder: a case study and a single case experimental design (SCED) study, (Doos Ali Vand, Gharraee, Asgharnejad Farid, Ghaleh Bandi, & Habibi, 2018a; Doos Ali Vand, Gharraee, Asgharnejad Farid, Ghaleh Bandi, & Habibi, 2018b). Both studies reported improvements in sleep-related variables (e.g., onset latency, quality, beliefs) and the SCED study also indicated improvements in emotion dysregulation, anxiety sensitivity, and neuroticism. The results of these studies provide preliminary evidence that the UP can lead to improvements in sleep and emotional outcomes. (Cassiello-Robbins et al., 2020)

Alvaro, P. K., Roberts, R. M., & Harris, J. K. (2013). A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression. Sleep, 36(7), 1059–1068. https://doi.org/10.5665/sleep.2810

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of abnormal psychology, 110(4), 585–599. https://doi.org/10.1037//0021-843x.110.4.585

Cassiello-Robbins, C., Southward, M. W., Tirpak, J. W., & Sauer-Zavala, S. (2020). A systematic review of Unified Protocol applications with adult populations: Facilitating widespread dissemination via adaptability. Clinical Psychology Review, 78, 101852. https://doi.org/10.1016/j.cpr.2020.101852

Khurshid K. A. (2018). Comorbid Insomnia and Psychiatric Disorders: An Update. Innovations in clinical neuroscience, 15(3-4), 28–32.

Vand, H. D. A., Gharraee, B., Farid, A.-A. A., Bandi, M. F. G., & Habibi, M. (2018a). Investigating the Effects of the Unified Protocol on Common and Specific Factors in a Comorbid Insomniac Sample: A Single-Case Experimental Design. Iranian Journal of Psychiatry and Behavioral Sciences, In Press(In Press). https://doi.org/10.5812/ijpbs.14452

Vand, H. D. A., Gharraee, B., Farid, A.-A. A., Bandi, M. F. G., & Habibi, M. (2018b). Investigating the Effects of the Unified Protocol on Common and Specific Factors in a Comorbid Insomniac Sample: A Single-Case Experimental Design. Iranian Journal of Psychiatry and Behavioral Sciences, In Press(In Press). https://doi.org/10.5812/ijpbs.14452

Question 19

Can chronic pain be treated with the UP?

David Barlow · Accepted Answer

Like many health conditions, chronic pain is associated with strong emotions like anxiety, depression, irritability, etc. Because the UP focuses on underlying psychological processes related to emotion regulation, there’s good reason to believe that it may be helpful for addressing some of the affective components of chronic pain. There have been some studies examining the efficacy of the UP for this particular application and initial results are promising, albeit preliminary. Guidance on application of the UP to chronic pain in an adult population (including a case example) can be found in “Applications of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders” (Payne, 2018).  https://global.oup.com/academic/product/applications-of-the-unified-protocol-for-transdiagnostic-treatment-of-emotional-disorders-9780190255541?cc=us&lang=en&

Payne , L. A. (2018). The Unified Protocol for Chronic Pain. In D.H. Barlow & T. J. Farchione (Eds.), Applications of the unified protocol for transdiagnostic treatment of emotional disorders. Oxford University Press.

Working with the Unified Protocol

Other Courses