Dr David H. Barlow And The Unified Protocol

He doesn’t really need an introduction. Professor David Barlow is a world-renowned researcher, psychologist, author, and thought leader. Best known for his work on anxiety and emotional disorders, he has published over 650 articles and chapters, as well as over 90 books and clinical manuals. Amongst his many influential roles, he has been President of the Division of Clinical Psychology of the American Psychological Association, Past-President of the Association for Behavioral and Cognitive Therapies, and was a member of the DSM-IV Task Force of the American Psychiatric Association. As Editor-in-Chief of the prestigious scientific advisory board for Treatments That Work™, David also oversees the review and evaluation of every treatment in the series to ensure it meets the highest standards of evidence.

To celebrate the addition of the Unified Protocol to our library, Psychology Tools were fortunate enough to sit down with David recently. We discussed some of the interesting history behind the development of the Unified Protocol, as well as the main benefits for clinicians and clients.

What are the main advantages of the Unified Protocol for clinicians?

I think that every clinician realizes that clients coming into their clinics with anxiety, depression, or what we classify generally as ‘emotional disorders’, very seldom have just one disorder. There’s always a question about what to tackle first, for example, if someone comes in with pretty severe social anxiety, they’re also having panic attacks, and maybe they’re a little depressed.

What a lot of clinics do, including ours for many years, is take a thorough look at the list of disorders, and then simply talk to the patient and ask what’s bothering them the most. The patient might say that it’s the social anxiety, so we agree to start there and tackle that. Then, at the end of the evidence-based protocol for social anxiety, the clinician, who is continually evaluating the patient, has to stop and say, “Now let’s start to look at your depression.”, and “What about the panic attacks?”.  If they don’t otherwise remit, these disorders are looked at one by one over time, each with a specific protocol.

Our view is that these disorders or symptoms are all of a piece – all facets of the same basic problem. So, the development of the Unified Protocol for The Transdiagnostic Treatment of Emotional Disorders is to take all those decision points and essentially make them unnecessary for the clinician. Instead, you can just say: “Okay, you’ve got a variety of difficulties with anxiety and depression. Let’s see if we can kind of get to the bottom of it and solve these problems”. The actual advantage would be that comorbidity and co-occurrence of disorders are taken off the table, you’re addressing all of them at once.

In addition, there is some evidence from our trials, which needs to be replicated, that we also cut down on attrition through using the Unified Protocol compared to treating each disorder singly. We’re not entirely sure why that is yet. It could be that the patients are more encouraged, or that we do focus a little bit on motivational enhancement.

How accessible is the Unified Protocol for practitioners to start using?

In terms of using the protocol itself, anybody trained in CBT can easily switch to the Unified Protocol (UP) transdiagnostic approach because the principal components of the UP are standard components of CBT, such as using cognitive reappraisal and various kinds of exposure treatments.

However, it’s a bit different conceptually. Let’s take panic disorder. Conceptually, the idea is that we’re not really treating the panic attacks specifically, since many people have occasional panic attacks, but the incapacitating anxiety about having additional panic attacks. That’s what really exacerbates the panic attacks and makes it panic disorder.

And for social anxiety disorder, we’re not specifically treating your ability to get up in front of people and say, “Good evening, ladies and gentlemen”, without falling over in a pool of anxiety, we’re treating the actual anticipatory anxiety that you’re having about it. We’re treating the common underlying mechanism that drives all of these disorders, using standard CBT procedures.

So, we think any well-trained CBT clinician can look at this protocol and understand they can use the same procedures but have somewhat different targets.

What is the best way to start incorporating the UP into your practice?

A good place to start is to have a look at the whole protocol first, and then go from there in terms of any training and what you might want to do. If you look on the Unified Protocol Institute (UPI) website, there are a number of virtual workshops and training sessions that happen fairly frequently. These introductory workshops are great chances to ask questions and might be a good way to develop some initial familiarity.

Equally, many clinicians just dive right into it – and that’s fine! They familiarize themselves with the protocol and they feel comfortable to start using it. They may have a few questions here and there, but as often as not, we’ll get feedback from someone who says, “I’ve treated my first 30 patients and I found it really useful. And by the way, here are the results.”

The Treatments That Work® series is written in a manualized, step-by-step format, specifically so that clinicians can pick up and learn the treatments easily. They are straightforward to follow and grasp, so well-trained students and clinicians should be fine.

What’s your perspective on protocols for single disorders now? Is there a place for both approaches and if so, how do you decide which to use? 

Well, we did develop some of these single diagnostic disorders in our clinic (e.g., for GAD, and panic disorder), so I have nothing whatsoever against them. Our view is that if you’re accustomed to using , let’s say, our panic disorder protocol and a client comes in with panic disorder as their major problem, then absolutely use what you’re most comfortable with as a clinician. But if you’re equally comfortable with the Unified Protocol, then the advantages we outlined earlier come into play. Your patient will almost certainly have several disorders and this approach would allow you to target all those disorders at the same time. But if you’re most comfortable with the panic disorder protocol, I would say go right ahead with that.

Where we see the biggest advantage is for new clinicians or clinicians in training. For them, rather than learn 10 different protocols for 10 different disorders, maybe you could start with just learning one. The whole notion is to make this more straightforward and more feasible for clinicians who are coming into practice.

As an aside, when we first started doing manuals, we designed them for single diagnoses. Panic disorder was one of the first to be published. In fact, David Clark and I probably had some of the first protocols for panic disorder out there, although there were some slight differences: David’s protocol had a cognitive emphasis, whereas ours had a more behavioral emphasis on exposure and response prevention.

As it turns out, there was an advantage to clinicians writing these protocols in terms of recognition and some possible royalties etc., and so it spawned this massive onslaught of protocols for each disorder. The poor clinician, who couldn’t possibly read them all, had to ask themself, “Well, which one do I choose? Which one is best? Which one will suit my purposes?”.

But generally, these single diagnosis protocols (and therefore the manuals), shared many of the same components, even though they were addressing different disorders. So again, that’s another reason to come up with a single transdiagnostic protocol that would cover a lot of disorders with one approach.

Can the protocol be used with groups as well as individual clients?

Well, that’s an interesting story – when we initially developed this protocol in the late 90s, it was designed to be applied to groups, and I ran all the early group sessions myself. Obviously, the practical advantages were substantial. In the old days, if we were trying to run a group for panic disorder patients, we had to wait until six or eight of them came in, and that might have taken months. But with a UP group, you just wait for the next six patients to come in with almost any kind of emotional disorder.

So, we tested it out and presented the concept to patients. We first tested whether a group of patients with different emotional disorders – from depression all the way over to a specific phobia – would understand the unified formulation that underpins the Unified Protocol when presented with it. Would they all really get it? Would they identify with it? We found out that they did, and, as in any good group therapy, they became close to one another and began helping each other out as we went through the protocol, no matter what their initial problem was.

Whether they had OCD with intrusive thoughts, or PTSD, the patients all grasped the general concept that they were reacting very intensely or emotionally to some specific trigger or cue. Whether it be signs of past trauma, beginning signs of a panic attack, or a possible upcoming social situation, they were all dealing with it in the same way by expressing intense anxiety, which they then attempted to suppress and avoid in any way possible. So, they did get it and that was a great start.

However, in the States, and to some degree in the UK as well, we largely depend on external funding for our research. In the States, we have the National Institute of Mental Health, which funds a lot of our programs, but when we put in our initial applications for funding research to support the protocol, there was a lot of misunderstanding about the approach. For example, the biological psychiatrists said, “How can you even think of treating OCD along with panic disorder? They’re biologically different in terms of the neural pathways that are activated, etc.”. We also got similar reaction from those working with psychosocial theories, who disagreed with our approach of treating people with different disorders in groups – even though we explained that we had done this successfully.

Because of all this, our initial grants and the protocols that resulted from them went in as proposing the treatment individually. When in fact, the whole point of it was for clinics to be able to put these patients together and treat them as groups!

Since then, we have looked at groups again and have published a number of chapters that describe the things to consider when applying this in a group format, and how it can work just as well. Those chapters are available now.

Can you pinpoint any standout moments where you realized the benefit and value of treating the commonalities between disorders, and what this could mean from a treatment perspective?

Well, it’s an interesting question. The process happened gradually and over a long time – for the whole field. During the 80s and 90s, David Clarke, Tim Beck, myself, and others, were doing our clinical research trials on anxiety disorders, depression, etc. We were so busy doing these clinical trials for the individual DSM or ICD disorders that we had essentially moved away from the notion that there is something common about these disorders.

However, around the year 2000, there was a specific trigger. I was reading a grant application from the Wellcome Trust by Chris Fairburn, the psychiatrist working on eating disorders – I’ve told Chris this story several times. In his application, he explained that we needed a transdiagnostic eating disorder treatment, because 50% of the people coming in with severe eating disorders don’t meet the criteria for any single eating disorder – for example bulimia or binge eating disorder, which was new on the scene. 50% of these people don’t fit neatly into any of those categories. We needed something that gets at the core of the problem – which he could see was body image distortion – and pathological attempts to manage that. I read that and said, “Yes, he’s absolutely right”, and, of course, he got the grant. This was actually the road we were going down for a while, but never finished. So, my colleagues and I sat down and wrote that first paper, and then we realized we could broaden our approach conceptually to include all of the emotional disorders.

Looking forward, what is your aim for UP for the next 10 years? Where do you think transdiagnostic approaches are going?

Well in some ways, as I said recently in Oxford, developing these programs is the easy part. We can do that in the confines of our clinical research where we can get our heads together and evaluate new strategies. The hard part is getting successfully evaluated interventions out there into the world and into the frontlines of care where people can use them effectively, because that’s what we developed them for. In other words, the next aim is greater dissemination and implementation of these protocols. Everyone’s working very hard on this! I’m convinced and optimistic about the progress of science, which is often slow and halting at times, but nevertheless, I think we’re making progress.

Our protocol has just been digitalized and we’re currently beta testing it in very large behavioral healthcare delivery systems. So certainly, the digitalization of our treatments is part of the plan and something that I think will make a difference. I think we have discovered very clearly that the old ‘horse and buggy’ approach to our treatments, where you have one highly trained therapist having in-person sessions with one client, is never going to touch the need that we have now. You can also look at the work David Clark and his colleagues are doing with the “talking therapies” initiative.  That program has really had an impact in the UK in terms of disseminating evidence-based psychological treatments, and it’s now being tried in Israel, Ontario, and other places around the world.

We are still trying to decide what the role of the therapist is within digitalized applications. How much of a therapist or a coach do we need along the way? This is all being worked out now, but I’m very optimistic that we’re going to come up with more efficient and effective ways to treat the many hundreds of millions of people who need our help on a larger scale. That’s the task of the next 10 years.

Further reading:

Barlow, D.H., Curreri, A.J., & Woodard, L.W. (2021). Neuroticism & disorders of emotion: A new synthesis. Current Directions in Psychological Science. 30(5),410-417. doi: 10.1177/09637214211030253.

Castro-Camacho, L., Barlow, D.H., Garcia, N., Farchione, T., Idrobo, F., Rattner, M., Quant, D., Gonzalez, L. & Moreno, J.D. (in press). Effects of a contextual adaptation of the Unified Protocol in multiple emotional disorders in victims of armed conflict in Colombia: A randomized clinical trial. JAMA Psychiatry.

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Latin, H., Sauer-Zavala, S.,…. Cassiello-Robbins, C. (2017).  Equivalence Evaluation of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared to Diagnosis-Specific CBT for Anxiety Disorders. JAMA Psychiatry, 74(9), 875-884. doi:10.1001/jamapsychiatry.2017.2164

Barlow, D.H., Farchione, T.J., Sauer-Zavala, S., Latin, H., Ellard, K.K., Bullis, J.R., ….Cassiello-Robbins, C. (2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist guide. (2^nd ed.) New York: Oxford University Press.

Barlow, D.H., Sauer-Zavala, S., Farchione, T.J., Latin, H., Ellard, K.K., Bullis, J.R., … Cassiello-Robbins, C. (2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Patient workbook. (2^nd ed.) New York: Oxford University Press.