Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data

The Unified Protocol (UP) is a transdiagnostic, emotion-focused cognitive-behavioral treatment developed to be applicable across the emotional disorders. The UP consists of 4 core modules: increasing emotional awareness, facilitating flexibility in appraisals, identifying and preventing behavioral and emotional avoidance, and situational and interoceptive exposure to emotion cues. Here we present data from 2 open clinical trials. In the first trial, an initial version of the UP was administered to a heterogeneous clinical sample, yielding significant pre- to posttreatment effects across disorders on a variety of measures. Analyses of clinical significance demonstrated modest results, with 56% of participants achieving responder status and 33% achieving high end-state functioning. Further manual development ensued, resulting in specific modifications and enhancements to core treatment components, and a second trial presents data from an additional pilot study of this revised version of the UP. Results from this trial demonstrated more robust treatment effects, with 73% achieving responder status and 60% achieving high end-state functioning. Results improved further at 6-month follow-up, with 85% classified as treatment responders and 69% achieving high end-state functioning. Implications for the treatment of emotional disorders as well as dimensional conceptualizations of psychopathology are discussed.     

Contextual Adaptation of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Victims of the Armed Conflict in Colombia: A Case Study

The delivery of a contextually adapted version of the Unified Protocol for transdiagnostic treatment of emotional disorders is illustrated through a case study of an internally displaced female victim of armed conflict in Colombia. A detailed account of how her history of continuous traumatic events and her forced displacement resulted in multiple emotional disorders and behaviors which hindered her ability to react to daily stressors illustrates the particular conditions of individuals exposed to extreme violence. Emphasis is placed on how her culture and context required adaptations of evidence-based interventions. The contextually adapted UP (CXA-UP) is described in “slow-motion,” through a session-by-session account of the procedure along with the specific changes in each module. Outcome measures showed four positive diagnoses at pretreatment, but none at posttreatment, 3-month, or 2-year follow-up. Implications for global applications with individuals in similar contexts and for widening access to such interventions are discussed.     

Changes in Risk Factors During the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

This study aimed to assess whether changes in potentially modifiable risk factors associated with the construct of neuroticism and common to emotional disorders (i.e., poor distress tolerance and heightened avoidance) occur in concordance with the administration of different treatment components of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and with reductions in emotional disorder symptoms (i.e., anxiety and depressive symptoms) overall. Using single-case analytic strategies, including multiple-baseline design and modeling techniques, the authors treated 8 adolescents with emotional disorder diagnoses and evaluated trajectories of change in distress tolerance and experiential avoidance as well as in the sequencing of such change in regard to change in anxiety and depressive symptoms. Clinical outcomes were favorable based on parent, adolescent, and clinician-rated measures. Treatment-based change was demonstrated, at both group and individual levels, and at expected points in treatment, in regard to facets of neuroticism. Overall, self-reported change in experiential avoidance and distress tolerance tended to occur simultaneously to reductions in emotional disorder symptoms. This study helps to clarify the course of expected change in variables believed to be common among a range of emotional disorders during a transdiagnostic treatment and provides initial information regarding tailoring the UP-A for individuals with different clinical profiles.     

Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C and UP-A) are evidence-based treatment programs with cognitive-behavioral and third-wave behavior therapy elements, aimed at extinguishing distress to intense emotion states and reducing unhelpful action tendencies in such states among youth with emotional disorders. A growing body of literature demonstrates the high prevalence of problematic anger and irritability among youth with emotional disorders, yet evidence-based treatments to address anger and irritability are typically developed more exclusively for youth with externalizing disorders. Given this need, a clinical case example of the UP-C applied to a child with anger and irritability is presented. Application of transdiagnostic theory to both conventional anxiety concerns and to irritability concerns is discussed. We demonstrate the flexibility and utility of a transdiagnostic approach like the UP-A and UP-C for addressing concerns across a range of emotions.     

Development of a Unified Protocol for the Treatment of Emotional Disorders in Youth

This study evaluated the efficacy of the Mind Reading interactive computer software to remediate emotion recognition deficits in children with autism spectrum disorders (ASD). Six unmedicated children with ASD and 11 unmedicated non-clinical control subjects participated in the study. The clinical sample used the software for five sessions. The control sample was evaluated only on pre- and post-test performance to assess practice effects. Results showed that participants with ASD scored significantly higher on the posttest than on the pretest. As level of emotion difficulty increased, mean scores on the pretest decreased, indicating that difficulty level had a valid effect. The Mind Reading computer software appears to significantly improve the emotion recognition abilities in children with ASD.     

Unified Protocol for the Transdiagnostic Prevention of Emotional Disorders: Evaluation of a Brief,Online Course for College Freshmen

The transition to college represents a period of increased risk for developing a range of mental health conditions, highlighting the need for effective preventive interventions delivered in this setting. The purpose of the present study was to explore the feasibility, acceptability, and efficacy of a preventive version of the unified protocol for college students; this intervention, called emotions 101 was provided in a very brief, online course format. Unselected students (N = 243) were randomized to either the course (n = 120) or wait-list (n = 123) condition, and all participants were asked to complete self-report measures of stress, negative affectivity, and quality of life at baseline, 1-month, 6-month, and 8-month follow-up time points. Despite recruitment challenges, once participants enrolled in the course, they were likely to complete it and provide favorable satisfaction ratings and qualitative feedback. With regard to efficacy, there were no significant differences on our primary (emotional) outcomes (i.e., stress, negative affectivity, quality of life) as a function of condition, though individuals randomized to receive the course demonstrated significantly higher grade point averages at the end of their first college semester than those in the wait-list condition. Taken together, the findings from the present study suggest that a very brief, online prevention program for emotional disorders administered in a healthy sample does not significantly impact mental health variables.     

Transdiagnostic and Transcultural: Pilot Study of Unified Protocol for Depressive and Anxiety Disorders in Japan

Unified protocol (UP) is a transdiagnostic cognitive behavior therapy for emotional disorders. It remains unknown whether UP is applicable for use in non-Western countries and for depressive disorders. We therefore examined its feasibility for a Japanese clinical population using this clinical trial design, which is multicentered, open-labeled, and single-armed (Clinical registry: UMIN000008322). The primary outcome was severity of anxiety symptoms, as assessed using Structured Interview Guide for the Hamilton Anxiety Rating Scale. Secondary outcomes were depressive symptoms, clinical global impression, functioning, quality of life, affectivity, emotion regulation, and adverse events. Of the 28 prospective participants, 17 were eligible and enrolled (depressive disorders = 9, anxiety disorders = 8). Severity of anxiety symptoms, which decreased significantly after the intervention, remained low for 3 months (Hedges’ g = 1.29, 95% CI = 0.56–2.06). Similar tendencies were observed for secondary outcome measures. No severe adverse event occurred. Two participants dropped out of the intervention. High treatment adherence and interrater reliability were confirmed. Results suggest the feasibility of UP in the Japanese context sufficient to warrant a larger clinical trial.     

Skill Acquisition During Transdiagnostic Treatment With the Unified Protocol

The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is an emotion-focused, cognitive-behavioral intervention developed to address the full range of anxiety, depressive, and related disorders. The UP consists of core therapeutic skills that, though unique in focus, are each designed to promote an approach-oriented stance toward emotional experiences. The goal of the present investigation was to characterize changes in these skills for patients that received a course of treatment with the UP, as well as to examine associations between skills and symptoms changes. Patients with principal anxiety disorders, assigned to receive treatment with the UP (N = 88) as part of a randomized controlled trial, were included in this study. They completed validated self-report measures of UP skills (Understanding Emotions, Mindful Emotion Awareness, Cognitive Flexibility, Countering Emotional Behaviors, and Interoceptive Awareness and Tolerance), as well as clinician-rated measures of psychological symptoms. Skill measures improved significantly over the course of 12 to 16 UP treatment sessions and changes in these skills measures were associated with improvements in anxiety symptoms. Determining whether improvement on all the skills learned during a course of treatment with UP is associated with symptom remission is critical to establishing the most streamlined and efficient interventions that may ultimately be best suited to widespread dissemination.     

Dimensional Assessment of Emotional Disorder Outcomes in Transdiagnostic Treatment: A Clinical Case Study

Current classification systems for mental disorders emphasize categorical assessment. In the domain of emotional disorders, this is inconsistent with a growing consensus that anxiety, depressive, and related disorders are best conceptualized as variations on shared underlying processes, chiefly heightened negative affect, and aversion to unwanted emotional experiences. Dimensional assessment of transdiagnostic emotional disorder constructs offers advantages for clinical and research applications, including increased parsimony and improved validity, yet there are drawbacks to many dimensional assessment systems for emotional disorders. The case presented in this paper illustrates the potential clinical utility of a new self-report instrument—the Multidimensional Emotional Disorders Inventory (MEDI)—which assesses nine dimensions characteristic of emotional disorders. MEDI scores for a highly comorbid patient are examined over the course of transdiagnostic emotion-focused cognitive-behavioral treatment. At baseline, midtreatment, and posttreatment, the MEDI offered information above and beyond DSM categorical assessment, including detection of subclinical symptoms and symptom change, while remaining parsimonious. Implications for possible use as a treatment planning instrument, integration with categorical assessment, and future research directions are discussed.     

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) Adapted as a School-Based Anxiety and Depression Prevention Program: An Initial Cluster Randomized Wait-List-Controlled Trial

Anxiety and depression are common debilitating conditions that show high comorbidity rates in adolescence. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich-May et al., 2018) is one of the few existing resources aimed at applying transdiagnostic treatment principles across the core dysfunctions implicated in the development of both anxiety and depression using a single protocol. This is the first known controlled study to examine the efficacy of the UP-A adapted as a nine-session universal preventive intervention program delivered in a school setting. A total of 151 students (mean age: 15.05) participated in this randomized wait-list-controlled trial conducted in Madrid, Spain. An unexpected decline in anxiety and depression levels from pre- to posttreatment and follow-up was found in both groups (p = .009, d = –0.22), and overall differences between conditions did not reach significance. Exploratory analyses of baseline emotional symptom severity as a potential predictor trended toward a significantly greater decrease in symptoms of depression for those with greater baseline emotional symptoms in the UP-A group compared to the wait-list-control group. Future trials with larger samples are justified to estimate the effect of the UP-A adapted as a selective prevention program for anxiety and depression.     

A New Unified Treatment Approach for Emotional Disorders Based on Emotion Science

ABSTRACT— Research on the nature of emotional disorders points toward a common set of diatheses (underlying psychological vulnerabilities) and functionally (but not superficially) similar expression of pathological emotional responding (e.g., Barlow, 2002 ). Successful drug treatments for different emotional disorders are very similar, with selective serotonin reuptake inhibitors or related compounds in wide use. Successful psychological treatments, on the other hand, are currently specifically targeted to each individual disorder. Distilling common principles among existing empirically supported psychological treatments, and giving attention to new findings on emotion regulation and dysregulation from emotion science, we propose and describe a new unified psychological treatment for emotional disorders.     

Acceptance and Commitment Therapy for Anxiety Disorders: Three Case Studies Exemplifying a Unified Treatment Protocol

Acceptance and Commitment Therapy (ACT) is an innovative acceptance-based behavior therapy that has been applied broadly and successfully to treat a variety of clinical problems, including the anxiety disorders. Throughout treatment ACT balances acceptance and mindfulness processes with commitment and behavior change processes. As applied to anxiety disorders, ACT seeks to undermine excessive struggle with anxiety and experiential avoidance––attempts to down-regulate and control unwanted private events (thoughts, images, bodily sensations). The goal is to foster more flexible and mindful ways of relating to anxiety so individuals can pursue life goals important to them. This article describes in some detail a unified ACT protocol that can be adapted for use with persons presenting with any of the major anxiety disorders. To exemplify this approach, we present pre- and posttreatment data from three individuals with different anxiety disorders who underwent treatment over a 12-week period. The results showed positive pre- to posttreatment changes in ACT-relevant process measures (e.g., reductions in experiential avoidance, increases in acceptance and mindfulness skills), increases in quality of life, as well as significant reductions in traditional anxiety and distress measures. All three clients reported maintaining or improving on their posttreatment level of functioning.     

Targeting Common Factors Across Anxiety and Depression Using the Unified Protocol for the Treatment of Emotional Disorders in Adolescents

Clinical approaches to mood and anxiety disorders in children and adolescents have historically been confined to either diagnosis- [e.g., for obsessive–compulsive disorder vs. generalized anxiety disorder (GAD), etc.] or domain-specific (e.g., for anxiety disorders vs. depressive disorders) treatments. However, as conceptualizations of mental illness shift towards a more dimensional model [e.g., the recent Research Domain Criteria (RDoC) from the National Institutes of Health], transdiagnostic treatments, such as the unified protocol for the treatment of emotional disorders in adolescents (UP-A; Ehrenreich et al. in Child Fam Behav Ther 31(1):20–37, 2008), are gaining support in the empirical literature. This paper reviews the common treatment targets across three emotional disorders commonly found in adolescence: GAD, social anxiety disorder, and major depressive disorder. In particular, similarities and differences across potential treatment mechanisms, including cognitive and information processing deficits, problem-solving difficulties, and avoidance strategies are examined. Finally, the case of 17-year-old “Andrea” is presented to demonstrate how transdiagnostic approaches like the UP-A can be effective in treating a range of emotional disorders in youth.     

Delivering Transdiagnostic Treatment Over Telehealth During the COVID-19 Pandemic: Application of the Unified Protocol

The COVID-19 pandemic has necessitated an abrupt transition to remote delivery of psychology services at a time when patients and practicing clinicians are experiencing an increase in life stressors (e.g., job loss, social isolation, need to adapt to telehealth practice), which can exacerbate mental health concerns and contribute to clinician burnout. Because the COVID-19 pandemic is affecting diverse individuals in myriad ways, these circumstances can elicit a wide range of emotions and emotional responses. Thus, treatment during this time must be able to address heterogeneous presenting problems while placing minimal burden on clinicians who are adjusting to continuously changing circumstances. Transdiagnostic, emotion-focused, cognitive behavioral treatments (CBT), such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), may be particularly well suited to address the challenges faced by practicing psychologists, and their patients, in the current COVID-19 pandemic. This paper discusses the applicability and adaptability of transdiagnostic treatments to telehealth, focusing primarily on the UP in the context of the COVID-19 pandemic. Further, while many CBT skills (e.g., mindfulness) can be easily translated to tele-delivery, other skills, such as exposure, can be more difficult to implement remotely, especially in the midst of a pandemic. Thus, this paper also provides practical suggestions for clinicians with regard to implementing the UP remotely.     

Toward a Unified Treatment for Emotional Disorders: Update on the Science and Practice

Mental health professionals have long been concerned with describing and proscribing a structure around the myriad variations of psychological and emotional distress that are deemed to be disordered. This has frequently been characterized as a conflict between so-called “lumpers” and “splitters”—those who advocate broad categorizations based on overarching commonalities versus those who endeavor toward a highly refined structure emphasizing unique characteristics. Many would argue that with the era of the modern Diagnostic and Statistical Manual of Mental Disorders (DSM-III to DSM-5), a splitting ideology has been dominant despite re-emerging concerns that some groups of diagnoses, particularly disorders of anxiety and other emotions, may be more similar than different. As a result of such concerns, transdiagnostic or unified models of psychopathology have burgeoned. In this review, we describe the work of Barlow, Allen, and Choate (2004), whose invited paper “Toward a Unified Treatment for Emotional Disorders” reignited transdiagnostic perspectives of emotional disorders. We provide an update on the scientific models and evidence-based treatments that have followed in the wake of this 2004 publication, including key areas for future study in the advancement of transdiagnostic and unified treatment of emotional disorders.     

Beyond Negative Affectivity: A Hierarchical Model of Global and Transdiagnostic Vulnerabilities for Emotional Disorders

Background: Negative affectivity (NA) has been linked to anxiety and depression (DEP). Identifying the common factors between anxiety and DEP is important when explaining their overlap and comorbidity. However, general factors such as NA tend to have differential relationships with different disorders, suggesting the need to identify mediators in order to explicate these relationships. Methods: The current study tests a theoretically and empirically derived hierarchical model of emotional disorders including both a general factor (NA) and transdiagnostic risk factors [anxiety sensitivity (AS) and intolerance of uncertainty (IoU)] using structural equation modeling. AS was tested as a mid-level factor between NA and panic disorder/agoraphobia, while IoU was tested as a mid-level factor between NA and social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and DEP. Data from 642 clinical outpatients with a heterogeneous presentation of emotional disorders were available for analysis. Results: The hierarchical model fits the data adequately. Moreover, while a simplified model removing AS and IoU fits the data well, it resulted in a significant loss of information for all latent disorder constructs. Limitations: Data were unavailable to estimate post-traumatic stress disorder or specific phobias. Future work will need to extend to other emotional disorders. Conclusions: This study demonstrates the importance of both general factors that link disorders together and semi-specific transdiagnostic factors partially explaining their heterogeneity. Including these mid-level factors in hierarchical models of psychopathology can help account for additional variance and help to clarify the relationship between disorder constructs and NA.     

Emotion Regulation in Youth with Emotional Disorders: Implications for a Unified Treatment Approach

Given the relationship between internalizing disorders and deficits in emotion regulation in youth, the emotion science literature has suggested several avenues for increasing the efficacy of interventions for youth presenting with anxiety and depression. These possibilities include the identification and addition of emotion-regulation skills to existing treatment packages and broadening the scope of those emotions addressed in cognitive-behavioral treatments. Current emotion-focused interventions designed to meet one or both of these goals are discussed, and the developmental influences relevant to the selection of emotion-focused treatment goals are explored using the framework of a modal model of emotion regulation. These various lines of evidence are woven together to support the utility of a novel emotion-focused, cognitive-behavioral intervention, the Unified Protocol for the Treatment of Emotional Disorders in Youth, a transdiagnostic treatment protocol that aims to treat the range of emotional disorders (i.e., anxiety and depression) simultaneously. Avenues for future directions in treatment outcome and assessment of emotion regulation are also discussed.     

Brief Transdiagnostic Intervention for Parents With Emotional Disorder Symptoms During the COVID-19 Pandemic: A Case Example

Concerns regarding parent mental health and well-being during the COVID-19 pandemic are justifiably on the rise. Although anxiety, depression, and traumatic stress levels have risen precipitously across all demographics during the pandemic, parents residing with their children are under particular and unique strain. Caregivers with children in the home are responsible not only for their own health, financial security, and safety during this time, but often full-time caregiving, household management and, in many cases, their children’s schooling. In this case paper, we describe the development of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Caregivers (UP-Caregiver) and provide a case example of its implementation. This 4-session indicated prevention for caregivers is a modification of existing versions of the Unified Protocols for adults and children, modified to maximize its responsiveness to issues faced by parents and caregivers living with youth (ages 6–13) during the current pandemic. UP-Caregiver was offered as part of a randomized, controlled trial via telehealth in a small group format to any parent with a child in the specified age range with mild or greater anxiety, depression or traumatic stress symptoms during an initial screening. The case example provided is of a White, Hispanic mother with a range of self-reported emotional disorder concerns at an initial assessment. Declines in anxiety, depression and traumatic stress symptoms were all noted, as well as improvements in parenting self-efficacy and distress tolerance 6-weeks after initiating UP-Caregiver. An ongoing randomized, controlled trial of UP-Caregiver will further evaluate the utility and feasibility of this approach to alleviate parental distress during COVID-19.     

Development and Implementation of a Transdiagnostic,Stepped-Care Approach to Treating Emotional Disorders in Children via Telehealth

Stepped-care interventions may increase the accessibility of evidence-based treatments but remain relatively underexplored in the child mental health literature. Further, while the feasibility and efficacy of stepped-care interventions have been examined for specific diagnoses or classes or disorders, transdiagnostic stepped-care interventions have not yet been developed. We discuss the development and initial implementation of a transdiagnostic approach to emotional disorders using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2018). A case series is presented to illustrate the delivery of UP-C stepped care (UPC-SC) via telehealth, using a collaborative decision-making process to inform step-up/step-down decisions. Lessons learned are discussed to guide refinements of UPC-SC and inform a larger trial.