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Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.

Dysregulated anger is often present in the emotional (i.e., anxiety, mood, and related) disorders; however, it is rarely targeted in treatment. Transdiagnostic treatments, which focus on processes that contribute to dysregulated emotions across the range of psychopathology, might represent an efficient way to treat this anger. Using a subset of data from a recently completed equivalency trial comparing the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) to single diagnosis protocols (SDPs) for specific disorders, this study began exploring whether the UP led to great reductions in anger compared with the SDPs. Results indicated that there was a small, nonsignificant, decrease in anger in the UP condition, whereas there was a moderate, nonsignificant increase in anger in the SDP condition. At posttreatment, UP patients had significantly lower anger scores than patients who received an SDP. These preliminary results suggest that transdiagnostic treatments may be well poised to target dyregulated anger in the context of emotional disorders.

We report on two approaches to addressing the problem of low reliability in the assessment of therapist competence in cognitive therapy (CT). In Study 1, we utilized ratings of a session from each of six therapists and investigated how CT experts evaluate specific therapist behaviors in making ratings on the Cognitive Therapy Scale (CTS). Departures from the consensus on judgments of these therapist behaviors were associated with more discrepant competence ratings. We take these results to suggest that, at least among experts, providing greater clarity about which therapist behaviors are relevant to each CTS item may enhance reliability. In Study 2, we utilize a sample of 14 therapists and pilot test a standardized assessment of therapist competence. The standardized assessment exhibited an intra-class correlation coefficient of 0.89 for a single rater. Standardized assessments of competence were related to four measures of therapist experience and qualifications, whereas the CTS was only related to two of these measures. With these promising initial results, we encourage future research to examine the predictive validity of standardized competence assessments in CT.

Psychotherapists routinely use both specific and non-specific strategies to deliver empirically supported treatments (ESTs). Psychotherapy adherence monitoring has traditionally focused on assessing therapist use of EST-specific strategies (to distinguish between ESTs), paying less attention to non-specific techniques common to multiple psychotherapies. This study used the Collaborative Study Psychotherapy Rating Scale (CSPRS) to evaluate therapist use of both specific and non-specific techniques in two affect-focused ESTs for depression. Blinded raters evaluated 180 recorded sessions of interpersonal psychotherapy (IPT) and brief supportive psychotherapy (BSP). Because IPT and BSP both emphasize attention to affective states and developing a warm therapy relationship, we expected overlap across scales measuring therapist warmth, empathy, and focus on feelings. In contrast, we expected differences in scales measuring therapist directiveness, as well as IPT- and BST-specific interventions. Results showed raters displayed good inter-rater reliability on primary subscales and could discriminate between two treatments with considerable overlap. Both IPT and BSP therapists used similarly high levels of non-specific, facilitative interventions. Expectedly, IPT therapists were more directive and used more IPT-specific strategies, while BSP therapists utilized more non-directive, supportive strategies. Unexpectedly, BSP therapists showed greater focus on feelings than IPT therapists. Exploratory analyses suggested that greater focus on feelings in early sessions was associated with greater depressive symptom reduction in the first eight weeks of treatment for both ESTs. Additional treatment adherence research is needed to investigate both shared and distinctive features of ESTs, as well as the effect of the relative use of specific versus non-specific interventions on psychotherapy outcomes.

The Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders is a cognitive-behavioral intervention designed to treat the range of anxiety, depressive, and related disorders. Thus far, the UP treatment modules have only been studied when they are delivered in their entirety and presented in a standard sequence. To personalize the presentation of the UP modules for a given patient’s presentation (e.g., providing the modules in a varied order, dropping irrelevant modules), it is first necessary to establish that each module leads to change in the skill it is designed to promote, and that these changes can occur in the absence of the other modules. Using a multiple baseline design in accordance with the single-case reporting guidelines in behavioral interventions (SCRIBE), eight patients with heterogeneous emotional disorders were randomly assigned to a 1- or 3-week baseline assessment phase followed by four sessions of one of four UP modules (psychoeducation, emotional awareness, cognitive flexibility, and countering emotional behaviors). Results provide preliminary support for the notion that each UP module under study leads to change in its associated skill in the absence of the other modules (five of eight patients demonstrated reliable change in the module-specific skill). In addition, exploratory analyses suggest that the emotion awareness training and cognitive flexibility modules appeared to exhibit change specific to their associated skills, psychoeducation, and countering emotional behaviors demonstrated somewhat more broad-based change across skills.

Numerous cognitive-behavioral treatment manuals have been developed to treat specific psychiatric disorders. Although these treatments are generally effective for those specific conditions, there remains a great need for interventions that can be flexibly applied across many disorders and symptoms due to high comorbidity rates and significant barriers to clinician training in distinct evidence-based psychological treatments. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a cognitive-behavioral treatment designed to treat neuroticism, a core temperamental factor that underlies the development and maintenance of emotional disorders (i.e., anxiety, depressive, and related disorders). In this chapter, we discuss the rationale for and conceptualization of the UP and its eight treatment modules. Since its development, the UP has garnered significant research support. As such, we detail findings from relevant research focused on treating depressive disorders and other related conditions. Finally, we describe each UP treatment module in depth and how providers can utilize the UP in their practice with patients with depression. Overall, the UP is a promising intervention that can be utilized across emotional disorders, including depression, and may be an intervention that is advantageous for widespread dissemination.

Both maladaptive and adaptive emotion regulation strategies have been linked with psychopathology. However, previous studies have largely examined them separately, and little research has examined the interplay of these strategies cross-sectionally or longitudinally in patients undergoing psychological treatment. This study examined the use and interplay of adaptive and maladaptive emotion regulation strategies in 81 patients receiving cognitive-behavioral interventions for comorbid alcohol use and anxiety disorders. Patients completed measures of emotion regulation strategy use and symptoms of psychopathology pre- and post-treatment. Cross-sectionally, higher use of maladaptive strategies (e.g., denial) was significantly related to higher psychopathology pre- and post-treatment, whereas higher use of adaptive strategies (e.g., acceptance) only significantly related to lower psychopathology post-treatment. Prospectively, changes in maladaptive strategies, but not changes in adaptive strategies, were significantly associated with post-treatment psychopathology. However, for patients with higher pre-treatment maladaptive strategy use, gains in adaptive strategies were significantly associated with lower post-treatment psychopathology. These findings suggest that psychological treatments may maximize efficacy by considering patient skill use at treatment outset. By better understanding a patient's initial emotion regulation skills, clinicians may be better able to optimize treatment outcomes by emphasizing maladaptive strategy use reduction predominately, or in conjunction with increasing adaptive skill use.

Dropout from mental health treatment poses a substantial problem, but rates vary substantially across studies and diagnoses. Focused reviews are needed to provide more detailed estimates for specific areas of research. Randomized clinical trials involving individual psychotherapy for unipolar depression are ubiquitous and important, but empirical data on average dropout rates from these studies is lacking. We conducted a random-effects meta-analysis of 54 such studies (N=5852) including 80 psychotherapy conditions, and evaluated a number of predictors of treatment- and study-level dropout rates. Our overall weighted dropout estimates were 19.9% at the study level, and 17.5% for psychotherapy conditions specifically. Therapy orientation did not significantly account for variance in dropout estimates, but estimates were significantly higher in psychotherapy conditions with more patients of minority racial status or with comorbid personality disorders. Treatment duration was also positively associated with dropout rates at trend level. Studies with an inactive control comparison had higher dropout rates than those without such a condition. Limitations include the inability to test certain potential predictors (e.g., socioeconomic status) due to infrequent reporting. Overall, our findings suggest the need to consider how specific patient and study characteristics may influence dropout rates in clinical research on individual therapy for depression.

Background: Previous research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population. Methods: The present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder. Results: We found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity. Conclusion: These results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.

Of any cluster of illnesses outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), none is more prevalent, likely to serve as a comorbid diagnosis, or costly in the United States than anxiety disorders. This chapter outlines the applications of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) for the treatment of such disorders. First, we briefly review the background research that provides context for the use of transdiagnostic treatment for anxiety disorders. The UP, with its intent to target comorbidity, is an approach that can be especially helpful for therapists who want to use an evidence-based treatment, prefer the structure of a manualized protocol, and value the benefits that a workbook can bring to patients. We then present two clinical case studies to demonstrate how each individual module of the UP maps onto typical cases of principal and comorbid anxiety. Recommendations for specific methods of protocol implementation are also described.

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.

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.

We provide a theoretical rationale for applying a transdiagnostic, shared mechanism treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders [UP]) to suicidal thoughts and behaviors. We also present results from a proof of concept study examining the feasibility and acceptability of adding a modified UP to treatment as usual (TAU) in an inpatient setting for individuals reporting a recent suicide attempt or active suicidal ideation. Participants ( N = 12) were randomly assigned to receive UP + TAU or TAU alone. Findings indicate good feasibility and acceptability of the adjunctive intervention. Among participants who were responsive to contact attempts postdischarge ( n = 6), there were no observable differences in suicidal thoughts or behaviors during a 6-month follow-up. This application represents a promising initial extension of a cognitive-behavioral, emotion-focused treatment to suicidal individuals within an inpatient setting. Future studies adequately powered to speak to efficacy of the modified UP intervention are warranted.

Anxiety disorders are a common class of disorders, and comorbidity among anxiety disorders is frequently observed. Cognitive-behavioral and behavioral psychotherapies for anxiety disorders are effective, though most evidence-based treatment protocols focus on the treatment of one principal anxiety disorder. In the last decade, treatments that aim to treat underlying vulnerabilities shared across anxiety disorders have been developed to more efficiently help patients that present with one or more anxiety and related disorders. We discuss two of these transdiagnostic treatments, the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, developed by David Barlow and colleagues, and Transdiagnostic Group Cognitive-Behavioral Therapy, developed by Peter Norton and colleagues. Background, similarities and differences, as well as evidence for each treatment are discussed. To date, the evidence from initial trials demonstrates efficacy for unified transdiagnostic treatments that is comparable to single-diagnosis protocols, providing promise for reducing therapist burden in acquiring and using evidence-based psychotherapies.

A substantial body of research has documented that the use of some coping strategies is associated with better psychological adjustment and superior physical health (Taylor & Stanton, 2007). In a recent meta-analysis, Aldao, Nolen-Hoeksema, and Schweizer (2010) reported that, across clinical and nonclinical samples, strategies involving problem solving and cognitive reappraisal were associated with fewer depressive symptoms. While researchers have recently focused on skill development among psychotherapy clients (Strunk, DeRubeis, Chiu, & Alvarez, 2007), relatively little is known about whether (or under what conditions) these skills are normally useful to people (who are not psychotherapy clients) coping with depressive symptoms that arise in response to everyday stressors. In this article, we examined whether variability in coping skills predicts depressive symptom reactivity (i.e., the extent of symptom worsening vs. improvement) in the wake of a series of commonplace stressors, namely, receipt of disappointing exam grades in a college class. We focused on depressive symptom reactivity over several days as we suspect the effects of coping skill use would likely occur over this relatively short interval. We further examined two potentially important contextual factors: depressive symptom severity and the degree to which stressors were associated with an affective reaction. We expected these skills would be more strongly predictive of depressive symptom reactivity among those with greater depressive symptom severity. In addition, as the use of coping skills has been proposed to be most beneficial on occasions when a notable affective shift has occurred (Beck, 1995), we expected coping skills to be more strongly related to depressive symptom reactivity on occasions involving these more marked affective reactions. Finally, we compared the predictive validity of skills assessed in the context of recurrent naturalistic stressors with a more commonly used one-time skill assessment method. Measuring Coping Skills Although various measures of coping skills exist, the Ways of Responding Inventory (WOR; Barber & DeRubeis, 1992) is well-suited to our purpose because it uses an open response format that is easily adapted to assess stressor-specific coping. The WOR presents participants with a series of challenging hypothetical situations (e.g., experiencing the sudden end of a relationship) and asks them to describe how they would cope with each situation. Using a manual, trained coders rate respondents’ descriptions according to the degree to which responses are consistent with adaptive coping strategies (e.g., considering evidence relevant to re-evaluation of an initial thought or generating a specific plan to cope). This rating procedure generates two summary scores: a total score and an overall quality score. The WOR Total score reflects the relative frequency of response segments deemed to be positive or negative (see Appendix for details), whereas the WOR Quality score reflects the overall quality of participants’ responses to each WOR scenario. Unlike the total score, quality scores are not constrained by the length of responses. With quality scores, raters can identify a single very positive response as reflecting more adaptive coping than two slightly positive responses. For this reason, we chose WOR quality scores as our primary coping measure. While the WOR was developed to measure skills taught in cognitive therapy (CT; Beck, Rush, Shaw, & Emery, 1979), there is evidence to suggest that meaningful variability in these skills exists among people who have learned coping skills naturalistically. In a college student sample, Barber and DeRubeis (1992) found a moderate relationship between better coping scores on the WOR and lower depressive symptoms. In a study of smokers, those with a history of depression reported poorer coping skills on the WOR than those without a history of depression (Haaga, Thorndike, Freedman-Wheeler, Pearlman, & Wernicke, 2004). Thus, meaningful variability in coping skills has been evident even among those who have not participated in CT. Although coping skills have been related to changes in depressive symptoms, it is unclear how well the WOR predicts coping with specific everyday stressors. Strunk and colleagues (2007) found that WOR scores were remarkably unrelated to a measure of the extent to which CT clients independently practiced using coping skills outside of therapy sessions. This finding has led us to wonder how well the WOR predicts respondents’ responses to real stressors. Compared with the WOR’s reliance on hypothetical situations, we suspected the assessment of coping following actual life events might provide a more precise estimate of coping skills as they are used. To the extent that the WOR does predict the use of coping skills in response to these stressors, the validity of the WOR would be supported. To the extent that use of coping skills in response to specific stressors is not well captured by the WOR, additional assessment strategies may be needed to capture individual differences in the use of coping skills. Coping Skills in Context: Depressive Symptoms and Affective Reactions Beyond examining whether coping skills are related to depressive symptom reactivity overall, we planned to examine two potentially important contextual factors: depressive symptom severity and the extent of affective reactions associated with a stressor. Aldao and colleagues (2010) found that the relation of coping strategy use and symptoms was stronger in clinical samples as compared with nonclinical samples-a finding that might be attributable to the higher symptom severity of clinical samples. With this in mind, we hypothesized that coping skills would be more consequential among those with greater depressive symptom severity. With regard to the strength of affective reactions as a possible contextual factor, we suspected that the extent to which one uses coping skills on occasions when stressors are accompanied by affective shifts is likely to be particularly important in determining the degree of depressive symptom reactivity on those occasions. Within the CT model, therapists emphasize the use of coping skills shortly after a mood shift occurs (Beck, 1995). As affective shifts are thought to identify periods in which emotionally salient thoughts have occurred, we expect the potential benefits of using coping skills to be of greater consequence on these occasions.

While a wealth of research has found that depressive symptoms are related to current attitudes, new evidence suggests depressive symptoms may be related to a fundamental deficit in forming new attitudes. Researchers investigating individual differences in attitude formation have found that depressive symptoms are strongly correlated with poorer learning of positive stimuli. This study extended these findings to a sample including clinically depressed participants. Results show that, as compared to nondepressed individuals, depressed individuals are characterized by a large deficit in their learning of positive stimuli. Implications of this fundamental deficit are discussed.

A substantial number of strong studies have established the efficacy of cognitive-behavioral treatment for persons with panic disorder with or without agoraphobia. These treatments include some combination of cognitive elements, exposure to interoceptive sensations similar to physiological panic sensations, in vivo exposure, and breathing retraining. A number of excellent studies have established the clinical efficacy of situational in vivo exposure for patients with moderate to severe agoraphobia and specific phobia. The most common treatment approaches for social anxiety disorder include social skills training, relaxation techniques, exposure-based treatment methods, and multicomponent cognitive-behavioral treatments.

Importance Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments. Objective To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders. Design, Setting, and Participants From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat. Interventions The UP or SDPs. Main Outcomes and Measures Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs. Results Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d , −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen d , −1.08; 95% CI, −1.43 to −0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-month follow-up (β, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. Conclusions and Relevance The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders. Trial Registration clinicaltrials.gov Identifier:NCT01243606