The Unified Protocol

Previous chapters in this book have been dedicated to exploring the use of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) with a variety of emotional disorders, and those chapters present compelling evidence for the efficacy of the UP across the range of these disorders. This evidence has now inspired further research efforts to better understand the contribution of individual treatment components, as well as to evaluate new methods of treatment delivery with the goal of furthering dissemination. The purpose of this chapter is to describe future directions and projects related to the UP, including dismantling studies, dissemination efforts, and the development of an Internet-delivered form of the intervention. Further, we discuss how these projects will enhance our understanding of the UP and how these endeavors will further a clinician’s ability to provide efficient, effective care.

The Unified Protocol for Eating Disorders

This chapter describes the application of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) to eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder, and other specified feeding or eating disorders. We focus on the five core treatment modules, highlighting aspects of each one that are particularly relevant to eating disorders and discuss the evidence supporting their use. Next, using clinical case examples from both residential and outpatient settings, we illustrate how each of these core modules can be applied to the treatment of eating disorders. Finally, we provide recommendations for future applications of the UP in this population.

The Unified Protocol for Bipolar and Comorbid Disorders

Bipolar disorder is a chronic and severe mental disorder characterized by affective lability and emotion dysregulation. In addition, it is associated with high rates of comorbidity, particularly with anxiety disorders. Approximately 90% of bipolar patients have been diagnosed with at least one comorbid anxiety disorder across the lifespan, with as many as two-thirds of patients meeting criteria for comorbid anxiety disorder at any given time. As such, transdiagnostic treatments that directly target emotion dysregulation in bipolar disorder are needed. In this chapter, we discuss evidence supporting an emotion dysregulation model of bipolar disorder and its roots in neuroticism. We then present a recent case of a patient with bipolar disorder with comorbid anxiety who received 18 sessions of treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP).

The Unified Protocol for Major Depressive Disorder

Major depressive disorder (MDD) can be a chronic, debilitating condition that for many individuals waxes and wanes over time. In addition, MDD and other unipolar depressive disorders demonstrate a high level of comorbidity with anxiety disorders. This chapter describes the application of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) to MDD and other unipolar depressive disorders. We first review research supporting the association between depression and higher-order constructs such as neuroticism. Next, we present a clinical case that, combined with module-specific recommendations, further illustrates how UP principles and strategies are implemented in the treatment of primary depression. Finally, we offer recommendations for future work involving the UP for major depression and other depressive disorders.

The Unified Protocol for Obsessive-Compulsive and Related Disorders

The case of a 25-year-old male with obsessive-compulsive disorder (OCD) is presented in this chapter. The patient, “Luke,” had primary obsessions related to harm befalling his family and girlfriend, as well as fears of contamination. His primary compulsions included mental “undoing,” in his words, and repeating actions. He engaged in significant avoidance around potential contaminants. The text reviews Luke’s course of treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), including the application of each treatment module and attention to challenging issues that arose in this case. Specific attention is devoted to the use of cognitive reappraisal in the UP for OCD, managing symptom accommodation by family members, and exposure in the context of intrusive thoughts and mental rituals.

Transdiagnostic Assessment and Case Formulation

This chapter describes a transdiagnostic, emotion-focused approach to case formulation that facilitates individualized application of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). We begin by highlighting the advantages of dimensional assessment and classification in the domain of emotional disorders. Next, we describe the elements of case conceptualization essential to the UP, including assessment of strong uncomfortable emotions, aversive reactions to emotional experiences, and efforts to escape or avoid these experiences. We provide examples of such processes, suggestions for how to elicit relevant information from patients, and a worksheet for conducting case formulation within the UP framework. Finally, we preview a recently developed self-report instrument that uses dimensional assessment to yield a transdiagnostic profile of emotional disorder features, which may further facilitate treatment planning.

Cross-Cultural Applications of the Unified Protocol

Growing evidence supports the importance of culturally adapting evidence-based interventions to increase their effectiveness and prevent treatment dropout. This chapter discusses several strategies for tailoring treatment to culturally diverse individuals and summarizes two cultural adaptations of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) in two countries, Japan and Colombia. In Japan, the protocol retained a high degrees of fidelity to the original UP while being translated into Japanese, adding illustrations, and changing the structure of the treatment goals. In Colombia, the protocol was culturally adapted to treat patients suffering from the aftereffects of trauma from the armed conflict. Descriptions of the cultural adaptations made to the protocol are outlined. In addition, a case from each setting is presented to illustrate the application of these adaptations.

Group Treatment Applications of the Unified Protocol

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated promising results among patients with heterogeneous anxiety and comorbid depressive disorders when delivered on an individual basis, but greater efficiencies may be achieved with group-based applications. This chapter will provide a rationale for utilizing a transdiagnostic approach in a group format, including cost-effectiveness and efficiency for patients and practitioners alike. It will illustrate a recent application of the UP with patients who completed 12 sessions in a group, offer guidelines on how to successfully implement the UP in a group of patients with a range of anxiety, depressive, and related disorders, and discuss the challenges that arose during treatment. We will then present data on the treatment response for each patient, as well as patients’ perceptions of the acceptability and feasibility of the UP in a group format, and conclude with our thoughts on future research priorities.

The Unified Protocol for Chronic Pain

Chronic pain represents a complex interaction of biological, psychological, and social factors and is associated with high rates of anxiety and mood disorders. Evidence now highlights the importance of potential common factors underlying both pain and emotions. One of these factors—neuroticism—has been linked with both mental and physical health concerns, including chronic pain. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) specifically targets neuroticism/negative affect and may be an ideal treatment to address both emotions and pain. This chapter describes the case of “Lisa,” a patient suffering with chronic pain and anxiety, and how specific components of the UP were applied to help her with her symptoms.

The Unified Protocol for Posttraumatic Stress Disorder

With the publication of DSM-5, posttraumatic stress disorder (PTSD) is no longer considered an anxiety disorder, but there is extensive evidence that PTSD is associated with high levels of comorbid mood and anxiety disorders. Although effective treatments exist for PTSD (e.g., Cognitive Processing Therapy), current treatments were not designed to target the full range of comorbid conditions associated with this disorder, and it is unclear whether these treatments are effective for comorbid conditions for individuals with PTSD. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), therefore, has great promise as a potential treatment for PTSD. This chapter reports the results of a case series of the UP for three individuals with a primary diagnosis of PTSD. Results of the UP were promising, with all three reporting a significant drop in symptoms of PTSD, anxiety, and depression. Implications for evaluating the UP as an alternative treatment for PTSD are also discussed.