Unified Psychodynamic Protocol for anxiety disorders

1. Introduction

Version followed: the nine-module UPP-ANXIETY as published in Leichsenring & Salzer (2014), Psychotherapy 51(2), 224–245 (doi:10.1037/a0033815). This is the only full protocol text drawn on. Its modules are: 1 socialisation; 2 motivation and goals; 3 alliance; 4 core conflict (CCRT); 5 warded-off wish/affect; 6 internalised object relations; 7 defences and avoidance; 8 response of self; 9 termination. The book versions (German 2018 "Angststörungen", English Hogrefe 2019) and the module list given in them (separate goal-setting, "function of anxiety" and "ego-function deficits" modules, disorder-specific add-ons) were not drawn on. Where that list differs from the 2014 paper, this guide shows where its content sits in the 2014 version and tags it [uncertain]. Session structure is filled in from the authors' own disorder-specific SET manuals for GAD (2014) and social phobia (2015), as far as their tables of contents show it. [source: Leichsenring & Salzer 2014; Hogrefe reading samples]

UPP-ANXIETY is a transdiagnostic, modular, short-term psychodynamic therapy for GAD, panic disorder (with or without agoraphobia) and social anxiety disorder. It is also proposed, with less evidence, for specific phobia, avoidant personality disorder and other anxiety presentations. OCD and PTSD are excluded. It is built on Luborsky's supportive-expressive (SE) therapy and borrows elements from panic-focused PDT (Milrod, Busch) and affect-phobia therapy (McCullough). [source: Leichsenring & Salzer 2014]

How change happens: anxiety is a signal of a feared wish or affect that is in conflict with an expected response from others. Avoidance, worry and panic work as defences that keep the conflict out of awareness. The therapy makes the conflict explicit as the patient's individual CCRT, or "anxiety formula". The patient then experiences the warded-off affect, tests the catastrophic expectations of others against reality, gives up the protective avoidance and builds a more encouraging way of relating to themself. The mechanisms the authors name are emotional and cognitive insight, tolerance and integration of affect, corrective experience, internalising an encouraging object, and a sense of control. [source: Leichsenring & Salzer 2014]

2. Framework

Format. Individual, face-to-face therapy of up to 25 sessions. The last three are booster sessions spaced two weeks apart. The therapist must already be trained in psychodynamic therapy. [source: Leichsenring & Salzer 2014]. Weekly frequency is the usual SE short-term default but the 2014 paper does not state it [uncertain]. The authors' disorder-specific SET manuals add probatory (assessment) sessions before session 1. [source: Hogrefe reading samples, GAD 2014 and SAD 2015]

Module architecture. Modules 1–3 are mainly supportive. Modules 4–8 are mainly expressive. Modules 3–8 are core and used in every treatment; 1, 2 and 9 frame them. The paper's Figure 2 shows the modules as overlapping cycles, not a strict sequence. Ambivalence (Module 2) and the CCRT (Module 4) are revisited throughout. The therapist adjusts the "dose" of each module to the patient's motivation and severity. [source: Leichsenring & Salzer 2014]

Practical phase map. The paper gives no per-module session counts. The map below borrows the phase lengths from the authors' SET manuals and is approximate.

Phase	Approx. sessions	Main modules	Goals
Probatory / pre-treatment	before 1	1, start of 2 and 4	Diagnosis, relationship-episode history, socialisation, treatment agreement
Initial	~1–8	2, 3, 4	Motivation and goals, alliance, CCRT formulated and shared as the "anxiety formula"
Middle	~9–16/17	5, 6, 7, 8 (cycling)	Affect focus, reality-testing the response of others, confronting defences and avoidance, encouraging self-dialogue
Closing	~17/18–22	9 (+ 7, 8)	Termination work, consolidation, attributing gains to the patient
Boosters	23–25, every 2 weeks	9	Relapse prevention, independent use of the anxiety formula

[source: phase lengths from the SAD manual TOC (1–8 / 9–16 / 17–22 / boosters 23–25) and the GAD manual TOC (1–8 / 9–17 / 18–25); module assignment is [synthesis]]

Criteria for moving on. The paper gives no formal transition criteria. It does give two sequencing rules: work through ambivalence enough before fixing goals, and when acute anxiety is high (e.g., panic), start with reassurance and a first psychological understanding of the symptoms. [source: Leichsenring & Salzer 2014]. Workable markers [synthesis]:

Into expressive work: the patient can state agreed goals, the alliance feels workable, and the CCRT has been shared and the patient recognises it as their own.
Into confrontation of feared situations (Module 7): the patient can name the wish and the expected response of others in at least one recent episode, and has experienced some of the warded-off affect in session.
Into termination: the patient uses the anxiety formula unprompted, has made real-life confrontations, and the date is approaching. Termination is fixed by the session limit, not by readiness.

Hinted module list mapped to the 2014 version [uncertain]: "setting treatment goals" sits in Module 2. "Function of anxiety" is spread across Module 1 (signal anxiety) and Module 7 (the defensive function of anxiety, worry and avoidance). "Deficits in ego functions" corresponds to the authors' transdiagnostic rationale (affect regulation, mentalisation, object relations) and to the rule of being more supportive when structural deficits are present. The book's disorder-specific add-on modules could not be verified.

3. Guiding principles

[source: Leichsenring & Salzer 2014 unless marked]

As expressive as possible, as supportive as necessary (Luborsky). Default to clarification, confrontation and interpretation, and shift to support when anxiety, crisis or structural weakness requires it.
The patient defines what is supportive. Judge a supportive intervention by the patient's experience of it, not by your intention.
Focus on one core conflict (CCRT). Bring every session back to the wish → expected response of others → response of self sequence and how it links to the anxiety.
Anxiety is a signal, and symptoms are compromises. Ask what the anxiety warns against and what the avoidance protects from, not only how to reduce it.
Target the feared affect, not the anxiety itself. Unlike CBT desensitisation, the work aims to make the warded-off wish or affect (often anger, guilt, shame or the wish for affirmation) tolerable and expressible.
Active therapist; goals limit regression. Be more active than in classical analysis, keep explicit goals in view, and do not encourage regression.
Confrontation of feared situations is necessary and is done by the patient alone. Encourage real-life confrontation, prepare it and debrief it, and link it to the CCRT. Do not accompany the patient.
Treat ambivalence empathically, and keep returning to it. Side with the anxiety's protective logic before questioning its cost.
Current outside relationships first; transference with care. Use transference interpretations sparingly and avoid them with more disturbed patients.
Common work. Frame the therapy as joint work and invite the patient to treat their problems the way the therapist does.
Monitor the alliance. Name and discuss ruptures in an accepting climate. Accept that affect focus may strain the bond for a while.
Working through happens within and between sessions. Assign self-observation of emotions and use of the anxiety formula between sessions.
Modular flexibility within a transdiagnostic frame. Use the same modules for every anxiety disorder and adjust the disorder-specific content (separation and aggression in panic, conflict-avoidant worry in GAD, shame and affirmation in SAD).
Gains belong to the patient. In ending, credit change to the patient's own work and tools.
Structural deficits are not an automatic exclusion. Raise the supportive share and lower the interpretive depth. Module 8 is not designed for severe self-pathology such as narcissistic or borderline personality disorder.
Additional principles from the SAD SET manual (chapter titles only) [uncertain]: giving information about the disorder; dealing with excessive standards; questioning sedating medication and substances; considering social-skills limits; attending to countertransference; "prescriptions"; humour. [source: Leichsenring et al. 2015 TOC]

4. Intervention inventory

Interventions are grouped by the 2014 module numbers. Short quotes in quotation marks are verbatim from Leichsenring & Salzer (2014), taken from the text-extracted PDF. Everything else is labelled (illustrative). Unless tagged otherwise, steps and "watch for" points are [source: Leichsenring & Salzer 2014] for what is done and [synthesis] for the step-by-step breakdown and the signs that it is working.

Module 1 — 4.1 Socialisation interview (role induction)

Purpose / when: Probatory sessions or session 1. Gives the patient a rationale and prepares them for an active role. Based on Orne & Wender's anticipatory socialisation. [source: Leichsenring & Salzer 2014]
Steps: (1) Ask what the patient expects from therapy. (2) Explain how this therapy works: talking about relationships and feelings, finding a recurring pattern, linking it to the anxiety. (3) Describe the patient's role (bringing concrete episodes, noticing feelings, eventually facing feared situations) and the therapist's role (helping understand, not giving advice). (4) Say now that facing avoided situations will come later in the therapy. (5) Check understanding and ask what doubts they have. Full procedure: the SAD manual (Leichsenring et al. 2007/2015), not drawn on.
Example language (illustrative): "Here we'll look closely at concrete situations with other people where the anxiety shows up, and find the pattern underneath. Later, when you're ready, we'll also work on gradually stopping the avoidance."
Watch for: Passive "fix me" expectations, and a patient who expects advice or medication. It is working when the patient brings specific episodes without being prompted.

4.2 Psychoeducation on signal anxiety and the disorder

Purpose / when: Module 1, repeated whenever needed. Turns the anxiety from something meaningless and overwhelming into something that has a function and can be understood.
Steps: (1) Normalise anxiety as an adaptive alarm. (2) Explain that in anxiety disorders the alarm also goes off for inner dangers: wishes and feelings that seem dangerous in relationships. (3) Describe the patient's disorder (e.g., panic does not come "out of the blue"). (4) Invite curiosity about what their alarm might be signalling.
Example language (illustrative): "Anxiety is an alarm system. Yours goes off very reliably, and part of our job is finding out what it's warning you about, sometimes something inside you rather than outside."
Watch for: The patient hearing "it's all in your head" as blame. It is working when the patient begins to wonder what triggers attacks or worry.

4.3 Treatment agreement and practical frame

Purpose / when: Module 1. Sets the frame that limits regression and makes termination predictable.
Steps: Agree on the number of sessions (up to 25, the last three spaced two weeks apart), the end date, timing, holidays and cancellations. Write these down. [source: Leichsenring & Salzer 2014]. The SAD manual calls the agreement session a "Paktgespräch" (pact talk). [source: SAD manual TOC]
Example language (illustrative): "We have up to 25 sessions; the last three are two weeks apart to help you practise on your own. Let's put the end date in the calendar now."
Watch for: Ambivalence showing up as uncertainty about scheduling. Take it to Module 2.

Module 2 — 4.4 Empathic interpretation of ambivalence ("siding with the anxiety")

Purpose / when: Early and then throughout, whenever motivation drops or avoidance increases. Acknowledges the protective value of the symptom so the patient does not have to defend it against you.
Steps: (1) Name the wish to change. (2) Name, with empathy, what the anxiety or avoidance does for the patient. (3) Present both sides without pushing. (4) Return to it whenever change slows.
Example language: SAD: "If you avoid meeting other people, they cannot humiliate you." GAD: "Worrying about your children prevents anything bad happening to them. What's wrong with that?" [source: Leichsenring & Salzer 2014]
Watch for: An ironic or sarcastic tone. The aim is to side with the anxiety, not mock it. It is working when the patient starts arguing for change themself.

4.5 Cost–benefit review of anxiety and avoidance

Purpose / when: Module 2, and again in Module 7. Brings out what avoidance costs.
Steps: (1) List what anxiety and avoidance protect the patient from. (2) List what they cost in work, love, self-respect and freedom. (3) Ask the patient to weigh the two lists. (4) Keep both lists for later goal reviews. [synthesis on the list format]
Example language (illustrative): "Staying home keeps the panic away. What has it cost you this year?"
Watch for: Intellectualised lists with no feeling. Slow down until a cost actually hurts.

4.6 Collaborative goal setting

Purpose / when: Module 2, after ambivalence has been worked through enough. Goals act as a measure of progress and a brake on regression.
Steps: (1) Agree on realistic symptom goals. (2) Add goals about the relational pattern and insight. (3) If the patient wants only symptom relief, link the symptoms to relationship problems to build motivation for the psychodynamic work. (4) Write the goals down and review them at set points.
Example language: PD: "You told me that you would like to get rid of your panic attacks." [source: Leichsenring & Salzer 2014]. Then (illustrative): "…and you also said the attacks started when things changed with your partner. Could understanding that be one of our goals too?"
Watch for: Grandiose or perfectionist goals (dealing with excessive standards is a SAD manual theme [uncertain]). It is working when the patient can say what progress would look like.

Module 3 — 4.7 Supportive alliance interventions (Luborsky)

Purpose / when: Core module, used throughout. Builds a secure helping alliance.
Steps: Express empathy and understanding. Explain the process. Set and monitor goals together. Acknowledge goals that have been reached. Use "we" language about the common work. Invite the patient to deal with problems the way the therapist does. Review motivation at intervals.
Example language: "You see, in fact, we are working together to achieve this." [source: Leichsenring & Salzer 2014]
Watch for: Support turning into reassurance-seeking. It is working when the patient uses "we" and brings material on their own.

4.8 Reassurance and early psychological understanding of symptoms

Purpose / when: At the start with highly anxious patients, especially in panic disorder (from Busch/Milrod). Brings arousal down enough for the work to start.
Steps: (1) Provide factual reassurance about the physical safety of panic. (2) Offer a first, tentative psychological link, e.g., attacks tend to cluster around separations or conflicts. (3) Reduce the reassurance as the patient's understanding grows.
Example language (illustrative): "These attacks feel like dying but they aren't dangerous. And I notice the first one came right after you moved out. Let's keep that in mind."
Watch for: Repeated demands for reassurance. Take these as material for the CCRT.

4.9 Alliance monitoring and rupture repair

Purpose / when: Throughout. Especially needed after affect-focused or confronting interventions, which can strain the bond. [source: Leichsenring & Salzer 2014, citing Crits-Christoph]
Steps: (1) Notice signs of a rupture (lateness, agreeing without engagement, withdrawal). (2) Ask about the relationship directly and without defensiveness. (3) Acknowledge your share. (4) Where it fits, link the rupture to the CCRT (expected response of others). [step detail: synthesis]
Example language (illustrative): "Last time I pushed on the anger and you went quiet. Did it feel like I was doing to you what you expect from others?"
Watch for: Patients with social anxiety and fear of humiliation may comply instead of complaining. Ask about ruptures actively.

Module 4 — 4.10 Relationship Episode interview (RAP)

Purpose / when: Probatory and early sessions. Collects the material for the CCRT.
Steps: (1) Ask for at least ten concrete interactions with specific others, recent and past (parents, partner, colleagues). (2) For each, get who, when, what was said, what the patient wanted, how the other responded, and how the patient felt and acted. (3) Include the onset of the anxiety, e.g., the circumstances of the first panic attack. (4) Mark wishes (W), responses of others (RO) and responses of self (RS). [source: Leichsenring & Salzer 2014; Luborsky 1984]
Example language (illustrative): "Tell me about a specific time recently with your boss: what happened, what you wanted, what he did, and how you felt and reacted."
Watch for: Vague, generalised accounts. Keep asking for the specific scene and the dialogue.

4.11 CCRT formulation shared as the "anxiety formula"

Purpose / when: Once the episodes show a pattern (end of the initial phase). Explains the symptoms and gives the patient a sense of control.
Steps: (1) Find the most frequent W, RO and RS across the episodes. (2) Put it in plain words. (3) Link each part to the anxiety, e.g., SAD: wish for affirmation → expected humiliation → avoiding exposure. (4) Present it as a hypothesis and refine it with the patient. (5) Ask the patient to look for it between sessions. Note: there is no single CCRT that belongs to a given anxiety disorder. [source: Leichsenring & Salzer 2014]
Example language: The paper's Module 4 example begins "As we have seen, you are not only afraid of exposing yourself…" [source: Leichsenring & Salzer 2014]. Illustrative: "Your formula seems to be: you want to be seen and appreciated, you expect to be laughed at, so you hide, and then the anxiety rises."
Watch for: Formulations that are too abstract. It is working when the patient recognises the pattern in a new episode on their own.

4.12 Linking onset and symptoms to the conflict (panic focus)

Purpose / when: Panic or agoraphobia, early. From panic-focused PDT.
Steps: (1) Reconstruct the first and the most recent attacks in detail: setting, relationships, feelings beforehand. (2) Look for themes of separation, individuation or anger. (3) Link these to the CCRT.
Example language: "You experienced your first panic attack when you thought of leaving your parents…" [source: Leichsenring & Salzer 2014, Module 7 example]
Watch for: The patient insisting the attacks are purely physical. Stay curious and keep collecting episodes.

4.13 Working through the CCRT across relationships (triangles of conflict and person)

Purpose / when: Throughout the middle phase. Malan's triangles fit with the CCRT.
Steps: (1) Trace the same pattern in current relationships (C), past relationships (P) and, where appropriate, the therapist (T). (2) In each, identify feeling (F) → anxiety (A) → defence (D). (3) Repeat in new contexts. Working through takes many repetitions.
Example language (illustrative): "It's the same with your partner as with your father: you want to say no, you fear he'll withdraw, so you agree and then lie awake worrying."
Watch for: Transference links with fragile patients. Keep to outside relationships (see 4.19).

Module 5 — 4.14 Affect clarification and focus on the warded-off wish/affect

Purpose / when: Core module, middle phase. Helps the patient experience the feared affect (often anger, guilt, shame or the wish for closeness or affirmation), including its bodily sensations, so it becomes tolerable. From McCullough's affect-phobia model.
Steps: (1) When the patient uses a global word ("upset", "stressed"), stop and ask for precision. (2) Ask where they feel it in the body. (3) Hold attention on the feeling instead of the story. (4) Notice when anxiety or a defence comes in (change of topic, a smile, intellectualising) and gently bring the patient back. (5) Name the wish the affect carries.
Example language: "You were 'upset'? Could you try to describe this feeling more precisely?" [source: Leichsenring & Salzer 2014]. Illustrative: "Stay with that for a moment. Where in your body do you notice it?"
Watch for: Anxiety flooding instead of affect. If so, slow down and use more support (4.22). It is working when the patient can name and stay with the feeling and the anxiety drops as the affect becomes clearer.

4.15 Imaginal affect exposure, then real relationships

Purpose / when: After the affect has been clarified. Builds tolerance by experiencing the feared impulse again and again, first in fantasy and then in actual relationships. Unlike CBT desensitisation, it targets the impulse and not the anxiety.
Steps: (1) Pick a CCRT episode. (2) Ask the patient to imagine expressing the wish or affect towards the other person. (3) Ask what would happen, and track the feeling and the anxiety as they come up. (4) Repeat until it can be tolerated. (5) Move on to planning real expression (4.16).
Example language: "What would happen if you do so?" [source: Leichsenring & Salzer 2014]. Illustrative: "Imagine telling her you're angry. What do you feel as you say it?"
Watch for: Imagined aggression that frightens the patient. Contain it and separate feeling from acting. It is working when the patient can imagine the scene with affect and without panic.

4.16 Finding functional ways to express the affect

Purpose / when: After affect tolerance has improved. Integrates the affect into the patient's way of relating.
Steps: Explore adaptive and assertive ways to express the wish or affect in the relationship concerned. Rehearse them in session if needed. Plan when and how.
Example language (illustrative): "How could you let him know you're hurt in a way that you'd respect afterwards?"
Watch for: Swinging from inhibition to outbursts. Review what happened after each attempt.

4.17 Between-session self-observation of emotions

Purpose / when: From the middle phase on. Working through outside the session.
Steps: Ask the patient to notice emotions, including bodily sensations, in everyday situations where the anxiety formula shows up, and to bring examples to the next session. [source: Leichsenring & Salzer 2014; format synthesis]
Example language (illustrative): "This week, when the worry starts, see whether there's another feeling just before it. Note it down and bring it."
Watch for: The task being done as a compliance ritual. Use what the patient brings, not whether the task was completed.

Module 6 — 4.18 Clarifying the worst-case response of others and reality testing

Purpose / when: Core module. Modifies internalised object relations, the RO part of the CCRT.
Steps: (1) Ask the patient to spell out the worst expected reaction to their wish. (2) Explore where the expectation comes from in their history. (3) Compare it with evidence from the current relationship. (4) Plan to notice how others actually respond (see 4.21).
Example language: "How would he react if you do so?" [source: Leichsenring & Salzer 2014]. Illustrative: "And when you did say no last week, what did she actually do?"
Watch for: Disconfirming evidence being dismissed as luck. Keep collecting it.

4.19 Corrective experience and careful transference work

Purpose / when: Throughout. The therapist's response differs from the expected RO and gives a corrective experience.
Steps: (1) Notice when the patient expects your criticism, humiliation or abandonment. (2) Respond in a way that does not confirm it. (3) Only with better-integrated patients, interpret the expectation in the here and now. With more disturbed patients, keep the focus on outside relationships.
Example language (illustrative): "You apologised three times for being late. Were you expecting me to be annoyed with you, the way your mother was?"
Watch for: Interpretations being heard as criticism. That is itself the RO being re-enacted, so repair (4.9).

Module 7 — 4.20 Interpreting the defensive function of anxiety, worry, panic and avoidance

Purpose / when: Core module. Shows that the symptom protects against something more unpleasant. This is the content of the hinted "function of anxiety" module [uncertain].
Steps: (1) Connect the symptom to the conflict it keeps away: panic ↔ separation or aggressive impulses; GAD worry ↔ avoiding conflict in relationships; SAD avoidance ↔ shame and the wish to be affirmed; AVPD ↔ defences that feel ego-syntonic, so make their cost visible. (2) Go over again what the avoidance costs. (3) Tie it back to the anxiety formula.
Example language: GAD: "By worrying all the time that something terrible will happen to your husband…" [source: Leichsenring & Salzer 2014]. Illustrative: "…maybe you don't have to feel how angry you are with him."
Watch for: Intellectual agreement with no change in feeling. It is working when the symptom drops after the affect is acknowledged.

4.21 Encouraging confrontation of feared situations (unaccompanied, CCRT-linked)

Purpose / when: Middle phase, once the CCRT is understood. Real-life confrontation of avoided situations. The authors treat it as necessary (citing Freud).
Steps: (1) Pick a meaningful avoided situation together with the patient. (2) Discuss beforehand what they expect, what they want and what they fear from others. (3) If social skills are lacking, rehearse the situation in fantasy first. (4) The patient goes alone; the therapist does not accompany them. (5) The patient observes their own reactions and those of others. (6) Debrief and link what happened to W, RO and RS.
Example language: "Thus, you need to stop avoiding it, you need to do it." [source: Leichsenring & Salzer 2014]. Illustrative: "Afterwards, tell me what you hoped for, what you expected from them, and what really happened."
Watch for: Safety behaviours or substance use during confrontation (the SAD manual questions sedating medication and substances [uncertain]). It is working when the patient's expectations get revised and avoidance decreases.

4.22 Confronting, clarifying and interpreting defences (McCullough)

Purpose / when: Whenever a defence blocks affect in session.
Steps: (1) Confront: point out the defence as it happens. (2) Clarify: explore how it works and when it started. (3) Interpret: what it protects against, and its cost. (4) Invite the patient to try going without it. The paper's example is a patient who talks about thoughts but avoids feelings.
Example language (illustrative): "You're telling me what you think about it, but I haven't heard what you felt. Shall we try?"
Watch for: Confrontation that feels like an attack. Pair it with empathy for why the defence was needed.

Module 8 — 4.23 Building an encouraging internal dialogue

Purpose / when: Core module, middle and late phases. Changes the response of self from self-criticism or avoidance to self-encouragement. With panic and GAD the tone is calming. Some patients "take" the therapist with them.
Steps: (1) Pick a situation the patient is about to face. (2) Ask what they could say to themself. (3) Help shape a realistic and kind statement. (4) The patient practises it in everyday situations, especially before confronting anxiety. (5) Review it.
Example language: "Is there anything that you can say to yourself that would encourage you?" [source: Leichsenring & Salzer 2014]
Watch for: Hollow positive self-talk. The statement should feel believable to the patient.

4.24 Perspective change

Purpose / when: Harsh self-devaluation, mainly in SAD.
Steps: Ask the patient to judge another person in the same situation, then compare that with how they judge themself.
Example language: "How do you feel about another person in your shoes?" [source: Leichsenring & Salzer 2014]
Watch for: "Others deserve kindness, I don't." Explore where that exception comes from.

4.25 Stage paradigm

Purpose / when: Social anxiety. Builds an observing, less self-critical stance (Hoffmann).
Steps: The patient imagines sitting in the audience and watching themself act in the feared situation on stage, then describes what the audience actually sees.
Example language (illustrative): "Picture yourself on stage giving that talk, and you're in row five watching. What do you see?"
Watch for: The audience view turning into the internal critic. Ask for a neutral or friendly observer.

4.26 Empathic recognition of earlier self-esteem injury (Kohut)

Purpose / when: When self-devaluation goes back to parents who undermined the patient.
Steps: Acknowledge how hard it was to endure parents undermining one's self-esteem, and link that to how the patient treats themself now.
Example language (illustrative): "It must have been very hard to keep any confidence when every attempt was criticised at home."
Watch for: Blaming the parents taking the place of change in the present. Keep coming back to current self-treatment.

4.27 Stopping in-session self-devaluation

Purpose / when: SAD, every time it happens in session (Hoffmann).
Steps: Interrupt the self-devaluation, name it, and invite a more accurate statement.
Example language (illustrative): "Let me stop you there. You just called yourself an idiot. Would you say that about a friend who did the same?"
Watch for: Feeling shamed by the interruption. Keep a warm tone.

4.28 Supportive adaptation for ego-function deficits

Purpose / when: Patients with structural weaknesses in affect regulation, mentalisation or object relations, or patients in crisis. The paper states only the principle of more support and fewer transference interpretations. The hinted module "improving underlying deficits in ego functions" could not be verified [uncertain].
Steps [synthesis]: Increase the share of supportive interventions (4.7 and 4.8). Name affects for the patient before asking them to explore. Shorten imaginal exposures. Keep to outside relationships. Use the goals as a structure.
Example language (illustrative): "Let's slow down. It sounds like several feelings at once. Shall we start with just one?"
Watch for: Fragmentation or dissociation under affect focus. Stabilise first.

Module 9 — 4.29 Termination reminders and marking milestones

Purpose / when: Throughout, increasing in the closing phase.
Steps: Remind the patient of the end date at regular points. Name milestones and breakthroughs as they happen.
Example language (illustrative): "We have eight sessions left. And what you did at the meeting last week was a real breakthrough."

4.30 Joint review of the work

Purpose / when: Closing phase. Consolidates insight and goal attainment.
Steps: Review the goals, the anxiety formula, what changed in W, RO and RS, and which tools helped. Plan for high-risk situations. [relapse-plan detail: synthesis]

4.31 Interpreting the return of symptoms around termination

Purpose / when: If symptoms come back as the end approaches. The CCRT is often reactivated by the fear of losing the therapist.
Steps: Link the flare-up to the coming separation and to the CCRT. Do not extend therapy automatically.
Example language (illustrative): "The panic came back just as we started talking about ending. Separation, again?"

4.32 Attributing gains to the patient

Purpose / when: Closing phase and boosters. Counters the belief that improvement belongs to the therapist.
Steps: Interpret the disowning of gains. Show that the patient used the same tools as the therapist.
Example language: "You believe that the gains you have made are not part of you…" [source: Leichsenring & Salzer 2014]

4.33 Booster sessions

Purpose / when: The final three sessions, two weeks apart. Practising independence and preventing relapse.
Steps: Review how the patient has handled situations on their own using the anxiety formula and the encouraging inner dialogue. Address any re-emerging avoidance. [content detail: synthesis]

Disorder-specific foci (2014 version; add-on modules from the book not verified [uncertain])

Panic / agoraphobia: first-attack circumstances; separation, individuation, aggression; fear of being trapped or helpless; losing protection or insecure attachment; reassurance early; unaccompanied confrontation.
GAD: worry as a defensive "fearful expectation" that avoids relationship conflict or worse experiences.
SAD: shame, wish for affirmation, fear of humiliation, self-devaluation; stage paradigm, perspective change.
Specific phobia: included, but simple phobias may suit CBT better.
AVPD: defences feel ego-syntonic, so make their cost visible. [source: Leichsenring & Salzer 2014]

5. Handling problems

The 2014 paper says little about problems. What it does say: return to ambivalence repeatedly, confront avoidance, discuss ruptures, use transference with care, give more support when patients are more disturbed, and expect early ambivalence work to reduce non-response and dropout (untested). The authors' SAD manual has chapters on treatment difficulties and non-response, but I saw only the titles. Everything else below is tagged [synthesis].

Patient wants symptom relief only, or doubts that "talking" helps. Link the symptoms to relationship episodes and give the anxiety-formula rationale again (4.2, 4.6). [source: Leichsenring & Salzer 2014]. Offer a short trial of looking for the pattern in the next attack or worry episode. [synthesis]
Ambivalence and resistance to change. Side with the anxiety (4.4) and do the cost–benefit review again (4.5). Don't argue for change; let the patient voice it. [source: Leichsenring & Salzer 2014]
Persistent avoidance / not doing confrontations (non-adherence). Find out which part of the CCRT the task touches (the feared RO) and interpret the avoidance as RS. Make the step smaller, rehearse it in fantasy first, and restate that confrontation is necessary (4.21). [source: Leichsenring & Salzer 2014 for the principle; grading: synthesis]. Avoid becoming a coach who accompanies or pressures. Pressure can re-enact a controlling RO. [synthesis]
Stuck at an intellectual level. Move from content to affect: confront the defence (4.22), ask for bodily sensation, slow the pace (4.14). [source: Leichsenring & Salzer 2014, after McCullough]
Overwhelm or panic during affect focus. Lower the intensity. Return to support and reassurance (4.8). Name the affect for the patient. Shorten imaginal exposure. Reinforce the encouraging self-dialogue (4.23). Resume expressive work once settled. [synthesis, consistent with "as supportive as necessary"]
Alliance rupture after confronting or affect-focused work. Expect it (the authors note the bond can weaken temporarily under affect focus). Name it, take your share, and link it to the CCRT if the patient can use that (4.9). [source: Leichsenring & Salzer 2014]. With SAD patients, ask about ruptures directly. Their fear of humiliation often hides ruptures behind compliance. [synthesis]
Reassurance seeking (panic, GAD). Give reassurance early, then reduce it and explore it as a wish for protection (the RO and W of the CCRT). [synthesis drawing on 4.8]
Worry that cannot be stopped (GAD). Treat worrying as a defence. Ask what feeling or conflict the worry keeps from awareness, and bring the patient back to the concrete relationship episode. [source: Leichsenring & Salzer 2014 for the defensive model; technique: synthesis]
Symptoms return near termination. Interpret the reactivation of separation fear (4.31). Hold the end date. Use the boosters. [source: Leichsenring & Salzer 2014]
Patient disowns progress. Interpret it (4.32). [source: Leichsenring & Salzer 2014]
Sedating medication, alcohol or substances used to avoid. The SAD manual addresses this, but its content is [uncertain]. Explore the substance use as a safety behaviour or RS in the CCRT, and coordinate any medication question with the prescriber. Give no dosing advice. [synthesis]
Severe personality pathology (borderline, narcissistic) or poor structure. Use the supportive adaptation (4.28). Avoid transference interpretation. Consider that Module 8 is not designed for severe self-pathology, and think about referring to a structure-oriented therapy (e.g., TFP, MBT). [source: Leichsenring & Salzer 2014 for the limits; referral: synthesis]
Comorbid depression or suicidality. Not addressed in the 2014 paper. Carry out a standard suicide risk assessment and safety planning according to local guidelines. Pause expressive work during acute risk. [synthesis]
Comorbid OCD or PTSD as the main problem. Outside the protocol's indication, so refer to an indicated treatment. [source: Leichsenring & Salzer 2014]
Non-response by mid-treatment (around session 12–16). Review the goals and the CCRT. Check whether the formula is wrong, whether confrontation has actually happened, and whether the alliance is real. Consider a different approach (e.g., CBT, especially for simple phobias) or combined treatment. [synthesis; the SAD manual has a chapter on non-response [uncertain]]
Countertransference (e.g., irritation with passive or reassurance-seeking patients, over-protectiveness). The SAD manual lists it as a principle [uncertain]. Use your own reaction as information about the RO the patient expects, and don't act it out. [synthesis]

Sources

Sources:

Books and papers cited (not drawn on unless listed above):

Leichsenring, F., & Salzer, S. (2014). A unified protocol for the transdiagnostic psychodynamic treatment of anxiety disorders: An evidence-based approach. Psychotherapy, 51(2), 224–245.
Leichsenring, F., & Salzer, S. (2018). Angststörungen (Unified Psychodynamic Protocol). Hogrefe. [uncertain]
Leichsenring, F., & Salzer, S. (2019). Anxiety Disorders: A Unified Psychodynamic Protocol. Hogrefe. [uncertain]
Leichsenring, F., & Salzer, S. (2014). Generalisierte Angststörung. Hogrefe (Praxis der psychodynamischen Psychotherapie, Bd. 4).
Leichsenring, F., Beutel, M. E., Salzer, S., Haselbacher, A., & Wiltink, J. (2015). Soziale Phobie: Psychodynamische Therapie. Hogrefe (Bd. 8).
Luborsky, L. (1984). Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment. Basic Books.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding Transference: The Core Conflictual Relationship Theme Method (2nd ed.). APA.
Milrod, B., Busch, F., Cooper, A., & Shapiro, T. (1997). Manual of Panic-Focused Psychodynamic Psychotherapy. American Psychiatric Press.
McCullough, L., et al. (2003). Treating Affect Phobia: A Manual for Short-Term Dynamic Psychotherapy. Guilford.
Orne, M. T., & Wender, P. H. (1968). Anticipatory socialization for psychotherapy. American Journal of Psychiatry, 124, 1202–1212.

Further reading (not drawn on): Europe PMC search; PMC article pages.

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