Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Therapist Guide

Many emotional disorders share common features. Three vulnerabilities which contribute to the development of anxiety, depression, and related disorder include the propensity to experience negative emotions frequently and intensely; a negative view of one’s emotional experiences; and a tendency to avoid or suppress negative emotional experiences in maladaptive ways which backfire.

Developed by David Barlow and colleagues, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition) helps therapists to target these vulnerabilities by guiding clients through 5 core treatment modules:

• Mindful emotion awareness. Teach clients to cultivate a curious, present-focused, and non-judgmental attention toward their emotional experiences.
• Cognitive flexibility. Encourage clients to identify biases and be more flexible in their thinking by using appraisal strategies.
• Countering emotional behaviors. Help clients to identify their avoidance behaviors, and encourage them to use alternative actions.
• Understanding and confronting physical sensations. Use interoceptive exposure to reduce the impact of strong physical sensations on emotion aversion and avoidance.
• Emotion exposures. Help clients design an emotion exposure hierarchy, and carry out exposures to increase tolerance for emotions, while learning more about them.

By targeting these core emotional processes that maintain symptoms across disorders, the Unified Protocol (UP) can not only address a wide range of presenting conditions, but it can simultaneously address co-occurring conditions. Backed by strong empirical support, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition) is a comprehensive program which offers clinicians guidance on using UP. The program includes two books:

• Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Therapist Guide details the step-by-step treatment of emotional disorders using UP, including common obstacles.
• Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Workbook is the companion to this therapist guide. It will help your patients to become active participants in their treatment and learn how to confront difficult thoughts and emotions, both independently and with the support of a therapist.

About Treatments That Work®

Authored by leading psychologists including David Barlow, Michelle Craske and Edna Foa, Treatments That Work® is a series of manuals and workbooks based on the principles of cognitive behavioral therapy (CBT). Each pair of books (therapist guide and workbook) – contains step-by-step procedures for delivering evidence-based psychological interventions and will help you to provide the best possible care for your clients.

At Psychology Tools, we are proud to make many of the Treatments That Work® titles available to our members. Each book is available to download chapter-by-chapter, and Psychology Tools members with a currently active subscription to our ‘Complete’ plan are licensed to share copies with their clients.

How effective is this treatment?

The UP has now garnered strong empirical support for its use with a range of emotional disorders. In a small, randomized controlled trial (N = 37), it was found to significantly reduce symptoms for a range of anxiety disorders compared to a wait-list control group, with patients continuing to improve even 18 months after treatment (Bullis, Fortune, Farchione, & Barlow, 2014; Farchione et al., 2012). The results of a subsequent, larger (N = 223) trial suggested that the transdiagnostic UP approach is just as good at addressing the primary disorder as the targeted protocol designed explicitly for that condition. Multiple systematic reviews and meta-analyses have offered support for the UP as an evidence-based, efficacious psychotherapy: a systematic review of controlled and uncontrolled studies indicated a moderate to large combined effect sizes for the treatment of anxiety and depression (Carlucci, Saggino, Balsamo, 2021); and a systematic review and meta-analysis demonstrated large effect sizes for symptoms of anxiety and depression, with moderate effects upon neuroticism / negative affect (Longley & Gleiser, 2023).

There is also preliminary data to support the use of the UP for emotional disorder patients with co-occurring alcohol abuse or dependence diagnosis (Ciraulo et al., 2013), unipolar depressive disorders (Boswell, Anderson, & Barlow, 2014), bipolar disorder (Ellard, Deckersbach, Sylvia, Nierenberg, & Barlow, 2012), borderline personality disorder (Sauer-Zavala, Bentley, & Wilner, 2016), and post-traumatic stress disorder (Gallagher, 2017). The protocol was originally developed in a group format (Barlow, Allen, & Choate, 2004), where patients reported comparable levels of satisfaction to those who had received it individually (Bullis et al., 2015).

Chapters in Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Therapist Guide:

• Chapter 1: Introduction to the Unified Protocol
• Chapter 2: Basic Principles Underlying Treatment and Outline of the Treatment Procedures
• Chapter 3: Additional Information for Therapists
• Chapter 4: Overview of General Treatment Format and Procedures
• Chapter 5: Session 1: Functional Assessment and Introduction to Treatment
• Chapter 6: Module 1: Setting Goals and Maintaining Motivation
• Chapter 7: Module 2: Understanding Emotions
• Chapter 8: Module 3: Mindful Emotion Awareness
• Chapter 9: Module 4: Cognitive Flexibility
• Chapter 10: Module 5: Countering Emotional Behaviors
• Chapter 11: Module 6: Understanding and Confronting Physical Sensations
• Chapter 12: Module 7: Emotion Exposures
• Chapter 13: Medications for Anxiety, Depression, and Related Emotional Disorders
• Chapter 14: Module 8: Recognizing Accomplishments and Looking to the Future
• Chapter 15: Using the UP in a Group Format
• Definitions of Key Terms
• References
• About the Authors

About the Authors

David H. Barlow, PhD, is Professor of Psychology and Psychiatry Emeritus and founder of the Center for Anxiety and Related Disorders at Boston University. He is editor-in-chief for the Treatments That Work series of therapist manuals and patient workbooks, as well as editor of The Oxford Handbook of Clinical Psychology. Dr. Barlow has published more than 600 articles and chapters and more than 80 books and clinical manuals, mostly in the area of the nature and treatment of emotional disorders and clinical research methodology.

Todd J. Farchione, PhD, is a Research Associate Professor in the Department of Psychological and Brain Sciences, Center for Anxiety and Related Disorders, Boston University. Dr. Farchione’s research focuses on the nature, assessment, and treatment of anxiety, mood, and related disorders. He has published more than 60 articles and chapters in this area.

Shannon Sauer-Zavala, PhD, is a Research Assistant Professor in Boston University’s Department of Psychology, as well as the director of the Unified Protocol Training Institute. Her research is focused on identifying factors that maintain symptoms across broad classes of psychological disorders and using this information to streamline treatment for commonly co-occurring diagnoses. Dr. Sauer-Zavala has more than 60 peer-reviewed publications in this area and is currently funded by the National Institute of Mental Health to continue this work.

Heather Murray-Latin, PhD, is a Research Assistant Professor in the Department of Psychological and Brain Sciences at Boston University.

Jacqueline R. Bullis, PhD, is an instructor in the Department of Psychiatry at Harvard Medical School and a clinical researcher in the Division of Depression and Anxiety Disorders at McLean Hospital. She completed her doctoral training in the clinical psychology program at Boston University.

Kristen K. Ellard, PhD, is an instructor in psychology, Harvard Medical School, and an Assistant in Psychology and Clinical Research Fellow at the Massachusetts General Hospital Department of Psychiatry’s Dauten Family Center for Bipolar Treatment Innovation and Division of Neurotherapeutics.

Kate H. Bentley, PhD, is a Clinical and Research Fellow at the Massachusetts General Hospital/Harvard Medical School and previously completed her doctoral training in the clinical psychology program at Boston University.

Hannah T. Boettcher, MA, is a predoctoral intern at the VA Medical Center in Lexington, Kentucky, and completed her doctoral training in the clinical psychology program at Boston University.

Clair Cassiello-Robbins, MA, is an advanced doctoral student in the clinical psychology program at Boston University.

Each Treatments That Work® title is published in two volumes:

• Clients use the Workbooks, which contain elements of psychoeducation, skills development, self-assessment quizzes, homework exercises, and record forms.
• Therapists use the Therapist Guides, which contain step-by-step instructions for teaching clients’ skills, overcoming common difficulties.

Although written for the client, the exercises in the workbook are intended to be carried out under the supervision of a mental health professional. The authors suggest that the most effective implementation of these exercises requires an understanding of the principles underlying the different procedures, and that mental health professionals should be familiar with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Workbook, as well as this therapist guide. Therapists with an active subscription to a Psychology Tools ‘Complete’ plan are licensed to use Treatments That Work® titles, and to download and share chapters with their clients.

• Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Towards a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230.
• Boswell, J. F., Anderson, L. M., & Barlow, D. H. (2014). An idiographic analysis of change processes in the unified, transdiagnostic treatment of depression. Journal of Consulting and Clinical Psychology, 82, 1060–1071.
• Bullis, J. R., Fortune, M. R., Farchione, T. J., & Barlow, D. H. (2014). A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Comprehensive Psychiatry, 55(8), 1920–1927.
• Bullis, J. R., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Carl, J. R., & Barlow, D. H. (2015). The unified protocol for transdiagnostic treatment of emotional disorders: preliminary exploration of effectiveness for group delivery. Behavior Modification, 39(2), 295–321.
• Carlucci, L., Saggino, A., & Balsamo, M. (2021). On the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders: A systematic review and meta-analysis.Clinical Psychology Review,87, 101999.
• Ciraulo, D. A., Barlow, D. H., Gulliver, S. B., Farchione, T., Morissette, S.
• B., Kamholz, B. W., . . . 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.
• Ellard, K. K., Deckersbach, T., Sylvia, L. G., Nierenberg, A. A., & Barlow, D. H. (2012). Transdiagnostic treatment of bipolar disorder and comorbid anxiety with the Unified Protocol. Behavior Modification, 36, 482–508.
• Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J., Carl, J.,... Barlow, D. H. (2012). Unified protocol for the transdiagnostic treatment of emotional disorders: A randomized controlled trial. Behavior Therapy, 43, 666–678.
• Gallagher, M.W. (2017). The unified protocol for posttraumatic stress disorder: A clinical replication series. In D. H. Barlow & T. J. Farchione (Eds.), Applications of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (pp. 11–126). New York: Oxford University Press.
• Longley, S. L., & Gleiser, T. S. (2023). Efficacy of the Unified Protocol: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology: Science and Practice, 30(2), 208.
• 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, 35–51.