The unified protocol for transdiagnostic treatment of emotional disorders
Authors: David H. Barlow, Bethany A. Harris, Elizabeth H. Eustis, Todd J. Farchione
Journal: World Psychiatry (2020)

Broadly defined, the fields of psychotherapy and psychopathology have been with us for well over 100 years, but in recent decades substantial paradigm shifts have occurred. In particular, classification of mental disorders shifted from a global set of descriptors based almost entirely on theoretical conceptions to a more atheoretical empirically derived and more narrowly construed set of criteria, resulting in a substantial increase in the total number of disorders. Paradigm shifts such as this often produce a substantial surge in research, which was indeed soon evident. In addition to ramping up research on neurobiological and cognitive bases of various disorders, these new more precise descriptions of psychopathology led to operational definitions of disorders as dependent variables. This development resulted in well-defined clinical trials typically evaluating either drugs or very specific psychological treatments targeted to the main features of each disorder1. These outcomes were seen as positive by most clinical scientists and, in the years following, enabled a closer look at commonalities among disorders, differences that define the disorders, and response to treatment. This was particularly true for a class of disorders we have come to refer to as "emotional disorders"2, comprising anxiety, depressive, and related disorders that constitute what used to be called the "neurotic spectrum" . Clinical scientists came to discover common neurobiological mechanisms underlying emotional disorders, and a hierarchical structure with dimensions of temperament at the top of the hierarchy, specifically neuroticism or negative affect and extraversion or positive affect3. Based on this research, we developed a single "transdiagnostic" treatment that no longer focuses directly on what we now regard as trivial symptomatic differences among disorders such as panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and depression, but rather targets their shared temperamental core4. Thus, the term "transdiagnostic" does not, in our view, simply refer to a treatment thought to be applicable across a wide range of psychopathology, as was true for old "schools" of psychotherapy, but rather to an intervention that targets specific psychopathological mechanisms (e.g., neuroticism) shared across a defined class of disorders2. The unified protocol for transdiagnostic treatment of emotional disorders (UP) is an emotion focused cognitive-behavioral intervention consisting of five "core" modules or components based on cognitive behavior therapy (CBT) elements of proven effectiveness that target negative emotionality and aversive reactions to emotions when they occur. These modules are preceded by an introductory session that reviews the patient's presenting symptoms and provides a therapeutic rationale, a module on motivational enhancement, and a module focusing on psycho­education about emotions. A final module consists of relapse prevention5. As the treatment proceeds, the domains of thoughts, physical sensations, and behaviors are each explored in detail, focusing specifically on elucidating dysfunctional emotion regulation strategies that the patient has developed over time within each of these domains, and teaching patients more adaptive emotion regulation skills. The UP has accrued substantial support for its efficacy in the treatment of anxiety and depression. In fact, a recent systematic review and meta-analysis examined 15 studies with a total of 1,244 participants and found large effect sizes across studies for symptoms of anxiety and depression when UP was delivered in both individual and group format6. Following two small open trials and an initial randomized controlled trial comparing the UP to a waitlist control condition, our group conducted a large randomized controlled equivalence trial (N=223) comparing the efficacy of the UP to established single-disorder protocols (SDPs) and a waitlist control condition. The UP was equally effective as SDPs in reducing symptom severity ratings across disorders, as well as decreasing symptoms of anxiety and depression, both at the end of treatment and at 6-month follow-up7. In addition, the UP condition exhibited lower rates of attrition over the course of the study. Meanwhile, other researchers have examined the efficacy of the UP in both individual and group contexts globally, including countries in South America, Asia and Europe. In general, these studies have also found the UP to be efficacious in the treatment of emotional disorders. While all humans experience emotions, culture can impact the messages one receives about the experience and expression of emotions, and the relevance of emotion regulation. Given that the majority of research has been conducted in Europe and the US to date, further research in other global contexts is warranted. As with any CBT, cultural competence is critical when using the UP. A promising recent pilot study conducted in Japan with the UP found significant reductions in symptoms of anxiety and depression that were large in magnitude8. The authors did not find any difference in emotion suppression from pre- to post-treatment, which they state is consistent with existing literature showing a lack of association between suppression and psychopathology in Japan, and may represent an important cultural difference to consider when delivering the UP. In another example, the UP has been adapted to fit the uniquely broad spectrum of cultures, education levels and backgrounds of victims of Colombia's armed conflict9. The UP has been translated into numerous languages, including Chinese, Dutch, German, Japanese, Korean and Spanish. An Internet-delivered version of the protocol has recently been developed. In summary, the UP provides a transdiagnostic psychological treatment that targets shared underlying mechanisms of all emotional disorders, thereby offering a single treatment that can be used across the most common clinical presentations. This treatment is equally effective as gold-standard SDPs, but may confer additional benefits with regard to efficiency, dropout, and training therapists. Given the unmet global demand for mental health care, combined with the lack of clinicians trained in evidence-based treatments, we believe that transdiagnostic treatments are the future of mental health care, and represent one approach to increasing access to evidence-based care and impacting global mental health.