David Barlow on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders

David Barlow on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders

by Lawrence Rubin
Renowned researcher, psychologist and professor David Barlow shares his decades-spanning career in the classroom, clinic, and laboratory in search of a Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders.

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Lawrence Rubin: Before we begin, Dr. Barlow, I'd like to congratulate you on being honored by the American Psychological Association with its Gold Medal Award for Lifetime Achievement in the Practice of Psychology. It's well deserved, and I applaud you. We often hear lifetime Award recipients say, "I'm not dead yet. I don’t need a Lifetime Award. I still have work ahead." So, is there any irony in receiving the Lifetime Award, over and above the gratitude that you have?
David Barlow: Well, you do have in the back of your head the notion that maybe they're trying to tell you something. But actually you know, I'm just about at the 50th anniversary of getting my Ph.D., so I certainly have been very blessed with a long and thoroughly enjoyable career. As I've said several times in talks of late, in all those years, I can never ever remember being bored for even an hour. 

Early Anxiety Research

LR: Your most recent work involves the development and testing of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, which primarily addresses anxiety and related disorders. And since anxiety is perhaps what you're most well-known for, I thought we could begin our conversation with anxiety and your work at Boston University’s Center for Anxiety and Related Disorders (CARD). You have dedicated your long career to the study and treatment of anxiety. What drew you in this direction and what's been enlightening and sustaining for you along the way?
DB: When I came on the scene in graduate school, I had the opportunity one summer to work in Boston with Joe Cautela, and also the South African psychiatrist Joseph Wolpe. People were very intrigued by what he was doing. He had developed an approach called systematic desensitization, the theoretical rationale for which turned out to be incorrect, but nevertheless it drove some of his work. What he did was take somebody with a phobia and have them gradually imagine being closer and closer to the phobic object or situation while in a very relaxed state. And he did it very gradually, because in those days we all thought, whether we were behavioral or psychoanalytic, that too much anxiety all at once was a very dangerous state of affairs that might lead to a psychotic break of some kind. So, this procedure turned out to be successful and people did seem to recover from their phobias. But of course in hindsight, it was not nearly as successful as it seemed to be at the time. That's often the case with new approaches. They seem more impressive at first than they turn out to be later.

Nevertheless, in those days, when we had very little in the way of more structured interventions, it was something people were intrigued with. And I trained with him, and so it was very natural when I went on to then do my doctoral work that I began to do my research on that technique and on its anxiety-reducing and phobic-behavior-reducing properties.
LR: So, you were entranced by Cautela’s and Wolpe's work. You saw it as a successful effort to address anxiety in a practical and effective way. What kept you in the anxiety game? For those therapists out there who search for specialties or search for an area that really grabs them, what was it about anxiety – it's ideology and its treatment – that really caught you and kept you?
DB: Well, I think there were several things.
First of all, anxiety is ubiquitous
First of all, anxiety is ubiquitous, as we now know. Everybody experiences anxiety. But in those days, we knew very little about it. We had not yet recognized that experiencing a panic attack was in some way unique and different from the more general background anxiety we all face. We had not yet really delineated the differences between anxiety and the day-to-day stress we all find ourselves under when we're challenged by one thing or another. So, it was very vague. People had not operationalized, as we say now in the game, the concepts of anxiety.

There was also very little connection with what we now call emotion science. In the old days, there used to be courses in motivation and emotion, but by the late '60s and early '70s, they began to fade away. And there was a long period of time when the basic field of studying emotion and motivation was under-emphasized and was often not taught in schools. So, it was such a common problem that we knew so little about. When we began to scratch the surface of it with Wolpe's early procedures which directly targeted the emotional symptoms of anxiety, we began to find out there was something there, but it did not work for the reasons Wolpe thought it did. He had a fancy kind of physiological theory about why it might work that was disproven rather quickly. And it was not as generally applicable as it would seem. And so, what was it about that procedure that at least benefited some people some of the time? Those are the kind of questions that we began to ask.

And, of course, to accomplish that, the other thing we did in the late '70s was to begin to study this in a real systematic way. I did my dissertation, as did many of my colleagues in those days, on female college sophomore who were afraid of snakes. And so did everybody else including my colleague Jerry Davidson. Why did we do that? Well, because it was so easy to find young women who were afraid of snakes. We'd just need to measure their fear. How afraid were they on a scale of zero to 10, and how close could they get to a snake in a cage? And we could then try different aspects of the treatment and look at the effects.

It wasn't too many years before we found out that that was all well and good, but it had very little to do with the kinds of patients we were seeing in real life, it did not transfer to the clinic, and to really find out something more important and more substantive, we had to begin working with patients. So, we established one of the first specialty clinics for people with anxiety disorders.

In those days, in clinical psychology and psychiatry, unlike medicine, we did not have specialty clinics that focused on a specific problem. Psychotherapy was kind of a general approach to a variety of problems people might have. But because we developed and then publicized this focus, we created a real niche. And it wasn't long before people were flocking to the clinic when we began to talk about what it was we were treating and began educating the public, often through the media, on what anxiety was, that panic was as a separate phenomenon, and the sorts of things we were beginning to do for it. And so, we had no shortage of patients, and that turned out to be a big reason for expanding research into the causes and treatment of these emotional disorders – much bigger than we thought it would be – in terms of playing into our training and research goals. 
LR: So, you saw a real need, not so much in the general, non-clinical population where anxiety was a day-to-day experience, but in clients who were struggling with anxiety at a level significantly higher and different than the average person, and that need caught your attention and just never let go.
DB: That's exactly right. And we found out that the simple, straightforward procedures like systematic desensitization, which were effective with less severe forms of emotional disturbance, often did not work with the more complex patients. Something was working, but we were not really sure exactly what was resulting in the positive changes we were seeing. What were we doing? What were the specific mechanisms or procedures we were using that seemed to be having an effect? And that started our program of research on really developing comprehensive treatments that had more general positive effects.
LR: So, you've always been interested in developing a real pragmatic, useful, and effective way to address, in this instance, an anxiety problem that's very, very common, that really didn't exist before beyond psychoanalysis, which had its own notions of anxiety as an overflow from unstable defenses.
DB: Yeah. We certainly shared with psychoanalysis that desire to come upon a set of principles that would be effective for anxiety disorders more generally. We also, in a separate but related line of research, began focusing on the nature of anxiety. You know, what was it that actually contributed to the development of really severe anxiety in people? What kind of personality characteristics? What kind of situational characteristics? What kind of early learning experiences contributed to this? Psychoanalysis, of course, had its hypotheses and theories, and then there were other theories coming out of attachment theory and the basic learning approaches in the laboratory. And we began another line of research which focused on, "How do these things all relate to each other? How do they come together?" And that was a very interesting parallel line of research.

Also, when the DSM came out, it had some similarities with previous versions, and also with the International Classification Disease schema that separated out the anxiety disorders. There were phobic neuroses -- social phobia, and generalized kinds of neurotic symptoms. And so, people would separate out these things. And often it was not based on a reliable way of identifying disorders or problems. It was relatively vague. Two clinicians looking at the same patient couldn't agree on what was said. So, we began another project to attempt to delineate the different presentations of anxiety and determine "how do they differ?" but also, "what do they have in common?" And over the decades, you know, in the '80s, we all focused on how they differed, and this resulted in a greater and greater number of disorders and treatments to address them. And then, in the late '80s and '90s, I began to think many of these things are very similar, and many of the treatments that we'd developed for these individual disorders such as panic disorder or obsessive-compulsive disorder or phobias, they really were very similar in many ways.
Maybe there were some common kinds of approaches underlying all of them that were really responsible for success.
Maybe there were some common kinds of approaches underlying all of them that were really responsible for success.

The Unified Protocol

LR: David, there is a symphonic piece by Bedrich Smetana called The Moldau which starts slowly and softly by depicting a small little rivulet at the top of a mountain, and then as that rivulet flows down, it joins others, and the music builds and builds. And by the end of it, there's a magnificent crescendo of this massive flowing river. As you're talking, my sense is that the Unified Protocol is something that wasn't born fully made. It's something that evolved from all your work and all your observations. And it just made sense that it should evolve, because your research determined that there are common factors underlying many anxiety disorders, and, therefore, why not look at a common set of treatments and treatment components to address those underlying common factors?

So, on the heels of that, can you describe the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders for those of our readers who probably have never heard of it? They've heard of CBT, they've heard of behavior therapy, but not the Unified Protocol
DB: Sure. I'd be happy to. And let me say, I think that's a very apt description about things coming together and forming a symphony, in some ways. But it's also important to add that it's not done yet. I think every month, every several months, the community of people doing clinical research and the community of people doing clinical work are getting their heads together and coming up with new issues that need to be added to this river to make it more comprehensive. But as it stands now we conceptualize what we are doing rather differently than we used to. We now approach these problems from the point of view of the overarching personality dimensions that are shared by these people.
Whether they have generalized anxiety disorder or depression or panic disorder or social anxiety disorder- they all share a personality trait or temperament called neuroticism
Whether they have generalized anxiety disorder or depression or panic disorder or social anxiety disorder- they all share a personality trait or temperament called neuroticism. Now clearly they had some other things going on that, in fact, define their disorders but we think that the basic overarching concept that actually has to be addressed is the neurotic temperament.And that neurotic temperament, as most everybody knows, has to do with a tendency to experience frequent out-of-control negative emotion and to be very reactive to that emotional experience because it seems out of one's control, it seems beyond one's ability to cope. And so, the Unified Protocol addresses this in what are now five core modules.

The first one would be making people more aware of their emotional life. People in the personality area and psychodynamic area talk of alexithymia or the difficulty in really recognizing or experiencing intense emotion. And so,
one of the things we do is help people to experience their emotion more fully
one of the things we do is help people to experience their emotion more fully. We have exercises to do that. We call them mindful awareness exercises, but they're a means to an end.

A second component would be helping them to recognize what kinds of attributions and appraisals they're making about their emotions. Not about the situation that provokes their emotions, but about the emotions themselves. And there's a lot that's very much like Beckian cognitive therapy in that approach.

Then, a third module helps people to focus on some of the somatic components of their emotional responses, of which they are often unaware. And so, we provoke, we examine, we evaluate the kinds of somatic symptoms that, for these people, signal the beginnings of intense emotion. For some, it's rapid breathing, kind of a hyperventilation. For others, it might be heart rate increases or decreases. Others may just have some feelings or sensations of unreality, some dissociation. And so, there's a variety of these somatic sensations that become important.

And then, we work on a fourth component, the tendency to avoid all emotional experience. And the avoidance obviously has long been recognized as a major part of all of the anxiety disorders, but the focus has been on the situations that are avoided, like a social situation or a crowded shopping mall for somebody with agoraphobia, or certain triggers or obsessions in somebody with OCD. But what we're focusing on is the avoidance of the emotion itself, which we think is what all these people have in common. And so, we work on identifying all the various subtle kinds of strategies our patients use to avoid experiencing any kind of intense emotion which, because of their temperament they feel, if it occurs, is out of their control and dangerous.

And then in a fifth module, finally, we put all these together into what we call emotion exposure exercises, where we have them experience intense emotions, often in context. We work with them in a collaborative fashion to provoke these emotions, and have them begin to experience these emotions in what ultimately would be a non-threatening way, as something that is a natural part of all of our existence, all of our behavior, and not something to be avoided at all costs.
if one does practice a greater awareness and acceptance of these kinds of emotional experiences, then they will repair naturally
And if one does practice a greater awareness and acceptance of these kinds of emotional experiences, then, in the lingo of the emotion theorists, they will repair naturally. They will diminish more quickly. 
LR: So, these are five core modules based on the underlying factors in the neurotic temperament that give rise to the various anxiety disorders, and then the actual specific techniques flow from these five core modules.
DB: That's correct. That's how we go about it now.

Whither the Dodo Effect

LR: There are numerous interventions for anxiety and related disorders, from psychoanalysis to somatic therapies, but there are those like John Norcross, Bruce Wampold and Michael Lambert who have proven through their research that all treatments are equally successful. And I don't know if that sends hackles down your back. But my question is, what is it about anxiety that lends itself so well to CBT? And conversely, what is it about the marriage of CBT and anxiety that's such a perfect union compared to these other treatments which these other folks say work just about the same?
DB: First of all, we do not agree with my good colleagues and friends John Norcross and Bruce Wampold that all treatments work the same. We think that's a gross oversimplification of the research literature. We think that there's irrefutable evidence that some psychological procedures and interventions work better than others-- they're not all CBT by the way. I think we're getting away from schools of therapy. As we're beginning to identify actual components of mechanisms of action of various therapies, we're finding that all therapies, to some degree, may have, more or less, some of these components.

However, if we look around the world at the various health care policy making organizations that make these decisions, such as the National Health Service in the U.K., the Veterans Administration Health Care system, and others – there are people who just look at whether there are some treatments that are better than others and should be first-line treatments, and they find that there are and then write them in the clinic practice guidelines. And these are continually being updated and revised based on the evidence, and they are not limited to CBT, by any means.

Having said that, it's very clear that the so called "common factors" of all therapies are very active in themselves and very important. Nobody would disagree, certainly not the CBT folks, that alliance and things like client/patient expectancies contribute to outcomes in therapy. What we would say, and I think what a lot of people in the psychotherapy field are now beginning to say, is that,
given that we know some of these "common factors" are important, maybe it's time we did some research on how we could make them even more powerful
given that we know some of these "common factors" are important, maybe it's time we did some research on how we could make them even more powerful.

Rather than simply doing one's psychotherapy and waiting for the expectancies to develop, we know that the social psychologists have spent a lot of time determining how we could really enhance expectancies. How could we shape expectancies among patients and clients and whomever we're working with so that they will be maximally effective? We think that those are important. They do contribute. They're not the sole determining factor; they're not the only factor. But they should, to the extent that they are useful, be enhanced. 
LR: Are you seeing the field moving in a way that utilizes CBT to enhance some of these common factors? Or could other therapeutic approaches also build on expectancy, alliance and rupture repair and those other relational variables? Or is it CBT that has the greatest promise for building on those factors?
DB: Well, if we look at, let's say, the anxiety disorders – and really I'm talking about the emotional disorders now, the depression and the various dissociative disorders and trauma-related disorders – we know there are some very powerful psychological procedures that, if used properly, are just as powerful as medications and have more enduring effects. One of them would be organizing, in a therapeutically beneficial way, exposure to anxiety- and panic-provoking cues. Without that kind of exposure, nothing we know of any substance is going to happen.

Now, if you look at the varieties of psychotherapy, you'll see that CBT focuses rather explicitly on that in the treatment of anxiety disorders, and it's proven time and time again to be powerful. But other approaches also tend to incorporate basic exposure, whether it's through narrative exposure or another approach. But to the extent that these therapies are different it may be that some of the CBT approaches have structured the exposure exercises in a more efficient and parsimonious kind of way. Another important mechanism that has been demonstrated time and again in both clinical and basic laboratories is altering the individual's attributions and appraisals of their own emotional experience and the context in which it occurs. And we all know cognitive therapy does that, but there are also other therapies that approach that in some ways.

So, we think there are some fundamental psychological strategies that are responsible for improvement in anxiety disorders. And these strategies can be enhanced by, let's say, focusing on expectancies and the alliance. So, for example, patients are going to be less cooperative with what, at times, is a difficult kind of exposure exercise if they have a therapist they don’t like telling them to do it. I mean, it's just as simple as that. Or requesting that they do it or working through it with them in some way. And similarly, if they have very little hope that these procedures are going to do anything worthwhile, then we know they probably won't.
LR: Based on our conversation, it's interesting that the notion of a “unified protocol” suggests more than just CBT, because you really are taking into account the research on common factors and relationship, and integrating those into a unified approach, recognizing that without a good relationship, without an attempt to directly address alliance and repairing ruptures, that none of these techniques, whether they be CBT-oriented or otherwise, will be effective. So, the unification of the protocol seems to now be grabbing on to these other common factors, and even more inclusively than I originally thought when I read your book on the Unified Protocol.
DB: Well, I think that's fair. Again, our emphasis would be that it's the psychological factors that are most central, and that the so called "common factors" of alliance and expectancy then contribute to the efficacy of those. You're just not going to have one without the other. Many people now see much of the future of behavioral health care, given the overwhelming needs in the population – even in our country, let alone underdeveloped countries – as focusing on different ways of delivering services. It's like tele-health, web-based interactive therapies, all the new apps that are able to reach so many more people.

A New Care Continuum

LR: Do you see those newer forms of service delivery, whether it's tele-health or apps, being a useful adjunct or component of the Unified Protocol as it evolves?
DB: I think they’re a useful component of all protocols to the extent that they're structured.
They are considered by many to be a new, more efficient way of reaching many, many more people than we would ever reach by individual doctor-level kind of therapy, small office therapy, one-on-one kind of therapy.
We need to develop some ways to be more efficient
We need to develop some ways to be more efficient.

Again, what I'm saying is, right now, it seems to be the case that when you approach the severe cases, you still need to have the therapist involved. But for the bottom half of the distribution of severity, it looks like this may be a much more efficient way to help people deal with their problems initially. So, it's a stepped care kind of approach. So, initiall we can implement self-help procedures, followed by maybe therapist-assisted procedures, and only for those who don’t benefit from those would you step up to the full therapeutic thing. 
LR: So, you don’t think that therapy through apps and telehealth are a threat to service delivery, but part of the growing continuum of connecting with clients based on severity and accessibility; that
these other delivery mechanisms can be part of a continuum of care rather than something that's sort of inimical to face-to-face care
these other delivery mechanisms can be part of a continuum of care rather than something that's sort of inimical to face-to-face care.
DB: I think not only can it be a part, but I think that it will be a part, given the overwhelming needs of people in society for the kinds of programs we have for them.
LR: On that note, how can the Unified Protocol be adapted to everyday practice, the line worker in the trenches in a community mental health center or a private practitioner who may not have the time or take the time to become familiar with or train in it?
DB: One of our hopes is that the Unified Protocol, containing as it does kind of five core modules, will be much more easily disseminated to our frontline clinicians working in the trenches. As we continue to distil these five protocols clinicians will see that they are not too awfully different from what almost most of them are already doing. The protocol would help them organize their approach in a more structured way and offer some quick and hopefully easily utilized assessment devices to incorporate into their practice. It saves them from learning one treatment for panic disorder, another treatment for OCD, a different treatment for depression.

A Few Remaining Issues

LR: Changing direction just a bit; kids seem to be epidemiologically at a much higher risk level for anxiety disorders. What are your recommendations with regard to applying the Unified Protocol or components of it with them?
DB: Certainly the
kids with internalizing disorders are at risk to develop more severe anxiety disorders later in life
kids with internalizing disorders are at risk to develop more severe anxiety disorders later in life even if they have mild kinds of internalizing symptoms. So, one of our colleagues, Jill Ehrenreich at the University of Miami, has developed the Unified Protocol for children and adolescents. There are slightly different versions for kids four to 10 or 11, versus adolescents, maybe 12 to 17/18, but they have the same principles.
LR: You suggest in your Unified Protocol training video that patients can continue medication throughout the protocol. Can you say a few words about the place of medication in the administration of the Unified Protocol?
DB: Well, the approach we learned to take decades ago is that it's obviously difficult to discontinue people from medication, and we find that, with these protocols, there's no need to. They wouldn't come to us unless they were continuing to suffer from their disorder. So, clearly medication, while perhaps benefiting them a little bit, has not mitigated the disorder to the extent that they don’t need any help. And we find that we can administer the protocol, and we simply tell them that they can keep taking their medication if they like.
We find that 40 to 50 percent begin cutting back on or discontinuing their medications anyway
We find that 40 to 50 percent, as the treatment progresses and they find they're getting better, begin cutting back on or discontinuing their medications anyway. For those people who do not feel that they can totally discontinue their medications but would like to, we can add on a few extra sessions to help them do that and we are also working with their internist or their prescriber. And then, for the minority of people who really seem to be very much addicted, as is often the case with the high-potency benzodiazepines, we have a few extra modules that are in a separate program that we recommend.
LR: Okay. So, you're not averse to medication. You respect the client's relationship with medication, and your program is not forcing clients/patients to make choices between talk therapy and medication therapy.
DB: That's exactly right.
LR: Let's say that you have a time machine and you're propelled into the future by 25 years, and it's the next generation of researchers and clinicians who have taken up your mantle on the Unified Protocol. What will it look like in 25 years?
DB: I don't know if I'll be around to see it, but I think it's a very exciting kind of question. I think
we're going to see the protocol expand a little bit to take in more transdiagnostic issues that seem to be very important in mental health
we're going to see the protocol expand a little bit to take in more transdiagnostic issues that seem to be very important in mental health. One of them, for example, is sleep. It's becoming increasingly apparent that sleep difficulties make a substantial contribution to all kinds of psychopathology. And so, it may be that there will need to be a component that specifically addresses sleep.

We also are learning increasingly, and we see this in the positive psychology field, that it may not be enough in many people, when we look at the broad kind of constructs of life satisfaction and thriving, just to eliminate some of the negative emotional aspects from which these people suffer. We developed a module recently, a brief module, that focused on increasing positive affect and positive emotional experience and enjoyment. So, I think we may see other strands coming from different theoretical persuasions that may well be integrated in this kind of approach for people with severe emotional disorders.
LR: David, I wish we could talk more because your thoughts and contributions have been so expansive, and your history is so tied to the history of psychology. So, I thank you.
DB: Thank you, Larry.

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David Barlow Dr. Barlow received his PhD from the University of Vermont in 1969 and has published over 500 articles and chapters and over 60 books and clinical manuals, mostly in the areas of anxiety and related emotional disorders, sexual problems, and clinical research methodology. He is formerly Professor of Psychiatry at the University of Mississippi Medical Center and Professor of Psychiatry and Psychology at Brown University, and founded clinical psychology internships in both settings.He was also Distinguished Professor in the Department of Psychology at the University at Albany, State University of New York and Director of the Phobia and Anxiety Disorders Clinic at the University at Albany, SUNY.

He joined Boston University in 1996 where he currently teaches.

He is Past-President of the Division of Clinical Psychology of the American Psychological Association, Past-President of the Association for Behavioral and Cognitive Therapies and was Chair of the American Psychological Association Task Force on Psychological Intervention Guidelines, as well as a member of the DSM-IV Task Force of the American Psychiatric Association.
Lawrence Rubin Lawrence Rubin, Ph.D. is a Florida-based psychologist and mental health counselor who is on the clinical faculties of St. Thomas University and the University of Massachusetts-Boston. He specializes in the assessment and treatment of children, teens and their families. He is also the editor at Psychotherapy.net