Unified Protocol

1. Introduction

Version followed: Barlow, Sauer-Zavala, Farchione, Murray-Latin, Bullis, Ellard, Bentley, Boettcher & Cassiello-Robbins, Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide, 2nd edition (Oxford University Press, 2018), with its Client Workbook (2018). The adult individual format is the default here. Where the 1st edition (Barlow et al., 2011) orders or names things differently, that is noted. The child and adolescent versions (UP-C, UP-A; Ehrenreich-May et al.) are separate manuals and are not covered.

• What it is: a modular, emotion-focused CBT for the "emotional disorders": anxiety disorders, depression, OCD, PTSD and related problems. One protocol targets the processes these disorders share, so you don't need a separate manual for each comorbid diagnosis. [source: FrancoAngeli Italian ed. of TG, ch. 1; Psychology Tools TG listing; Frank & Ritchey 2015]
• Model of change: people with emotional disorders have frequent, intense negative emotions (neuroticism). They also react to those emotions as bad or dangerous, for example by seeing them as weakness. That aversive reaction drives avoidance and suppression, which brings short-term relief but raises future negative emotion and keeps symptoms going. The UP aims to change how clients respond to emotions, not to remove the emotions. It does this by building willingness to experience emotions and by reducing avoidance, using mindful awareness, reappraisal, changing emotion-driven action tendencies and exposure. [source: FrancoAngeli TG ch. 1; Sauer-Zavala et al. 2021]
• Treatment goal (practical): clients learn that emotions are useful, temporary and tolerable. They stop letting avoidance decide what they do, and lower neuroticism over time. [source: Sauer-Zavala et al. 2021; FrancoAngeli TG ch. 1]

2. Framework

Sequence (2nd ed.) [source: FrancoAngeli TG table of contents; Psychology Tools TG and Workbook listings]

Core modules. Modules 3 to 7 are the five "core" skill modules. The 2015 Pittsburgh training slides note that the physical-sensations module is completed even when bodily sensations are not the client's main focus. [source: Psychology Tools TG; Frank & Ritchey 2015]

Session count and format

• Typical length: 12 to 16 weekly individual sessions. In the large equivalence trial this meant 16 sessions within 21 weeks for GAD, social anxiety and OCD, and 12 sessions within 16 weeks for panic disorder. All eight modules were delivered whatever the session count. [source: Sauer-Zavala et al. 2021; UP Institute research page]
• Earlier and adapted versions: earlier trials used up to 18 sessions. One example plan from a 1st-edition-style trial: motivation in session 1, psychoeducation in 2, awareness in 3–4, cognitive flexibility in 5–7, emotion-driven behaviours in 8–11, physical sensations in 12–15, exposure in 16–17 and summary in 18. [source: Frank & Ritchey 2015; Trials 2015 table 1]
• Other formats:
  • Group format, about 90-minute sessions, including online: one example delivered eight modules in 12 sessions. [source: Arrigoni et al. 2021]
  • Internet-delivered, intensive or massed, and single-session workshop formats. [source: UP Institute research page]
  • A five-session version ("UP-5"). [source: NCT04837521 protocol]

Monitoring

• The OASIS and ODSIS are brief five-item self-report scales of anxiety and depression severity and impairment. Each is scored 0–4 per item, giving totals of 0–20. They are used to track outcome. [source: Arrigoni et al. 2021]
• [uncertain] The 2nd-edition guide has clients rate both scales weekly and plot them on a progress record (workbook ch. 3, "Learning to Record Your Experiences"). The chapter title is confirmed; this detail of its contents is unconfirmed. Do not reproduce the scale items; obtain the scales from the publisher or developers.

Criteria for moving between modules

• Therapists decide flexibly how many sessions to spend on each module. [source: Sauer-Zavala et al. 2021]
• [synthesis] Move on when the client can explain the module's concept in their own words and has used the skill outside sessions at least a few times, with real examples on their forms. Do not wait for mastery. Later modules practise earlier skills again, and Module 7 is where Modules 2–6 come together. [source for the last point: Sauer-Zavala et al. 2021]
• [synthesis] Spend more time on a module when its target dominates the case formulation, for example Module 4 for heavy worry or rumination, or Module 6 for panic or health anxiety. Do not drop core modules: the trial protocol delivered all of them.

Typical session structure [synthesis; consistent with the TG's "general format" chapter]

1. Review the OASIS and ODSIS scores and the progress record.
2. Review homework.
3. Introduce the new skill, linking it to the client's own ARCs.
4. Practise in session.
5. Assign home practice and the matching form.

3. Guiding principles

[source for the model: FrancoAngeli TG ch. 1; Sauer-Zavala et al. 2021; Psychology Tools TG. One-line translations are synthesis.]

• Emotions are functional, not the enemy. Practical meaning: never set "feel less anxious or sad" as the target; the target is responding differently to emotion.
• The target is the reaction to emotion. Practical meaning: in every formulation, ask how the client judged, resisted or avoided the feeling, not only what they felt.
• Avoidance maintains the disorder. Practical meaning: hunt for avoidance in all its forms, including subtle and cognitive avoidance and safety signals, and design practice that removes it.
• Transdiagnostic and dimensional. Practical meaning: formulate across all the client's diagnoses at once; comorbidity is expected, not a reason to switch manuals.
• Modular but sequenced. Practical meaning: follow the order (awareness, then flexibility, then behaviour, then sensations, then exposure), while adjusting time per module to the case. [source: Sauer-Zavala et al. 2021]
• Nonjudgmental, present-focused awareness is the base skill. Practical meaning: before changing anything, the client must be able to observe the thought, sensation and behaviour parts of an emotion as it happens.
• Flexibility, not "correct" thinking. Practical meaning: aim for more than one possible interpretation, not for replacing a bad thought with a good one. [source: Sauer-Zavala et al. 2021]
• Exposure is for learning, not habituation alone. Practical meaning: the point of an emotion exposure is to learn that the emotion is tolerable and passes. [source: Sauer-Zavala et al. 2021]
• Collaboration and home practice. Practical meaning: skills grow between sessions, so review homework every session and work out obstacles together. [source: sobrief summary of TG, secondary]
• Motivation is worked on throughout, not checked once. Practical meaning: return to the client's goals and decisional balance whenever engagement drops. [synthesis from Module 1 title, "Setting Goals and Maintaining Motivation"]
• Medication is compatible. Practical meaning: the UP gives clients information on medication. [synthesis] Consider whether as-needed medication is working as a safety signal. [source for medication chapter: FrancoAngeli TG table of contents]

4. Intervention inventory

Sources and limits for this section:

• Module names, order and core purposes are confirmed from the TG and workbook tables of contents and from the descriptions in Sauer-Zavala et al. (2021), Frank & Ritchey (2015), NCT04837521 and the Trials tables.
• The full manual text was not openly accessible. Step-by-step instructions are therefore my operational rendering of each confirmed component [synthesis], unless tagged otherwise.
• Items whose exact 2nd-edition name or procedure is unconfirmed are tagged [uncertain].
• All example language is illustrative.

4.1 Functional assessment (Session 1)

• Purpose: map how the client experiences and responds to emotions across all presenting problems, and set up treatment. [source: TG ch. 5 title "Session 1: functional assessment and introduction to treatment", FrancoAngeli TOC]
• Steps [synthesis]:
  1. List the current problems across diagnoses.
  2. For two or three recent episodes, get the trigger, then thoughts, body sensations and behaviours, then what happened short-term and long-term.
  3. Ask what the client does to make the emotion stop or not happen: avoiding, checking, reassurance, distraction, substances, withdrawal, safety items.
  4. Name the common thread: strong emotions, a negative judgement of them, then avoidance that helps now and backfires later.
  5. Outline the eight modules and the expected length.
  6. Start monitoring.
• Example language (illustrative): "Your panic, your worry about work and your low mood look different, but each time you describe a strong feeling, then trying hard to get away from it. That pattern is what we'll work on."
• Watch for: the client hearing "transdiagnostic" as "not tailored to me". Use their own examples. It is working when the client can recognise the feel-it, judge-it, avoid-it sequence in their own episodes.

4.2 Progress monitoring (OASIS, ODSIS, progress record)

• Purpose: track anxiety and depression severity and impairment across the course of treatment. [source: Arrigoni et al. 2021 for the scales' format]
• Steps:
  1. Give both scales at intake. [uncertain] The manual has them completed before each session and plotted on a progress record; this is unconfirmed.
  2. Look over the graph together at the start of each session.
  3. Link changes to skills used that week. [synthesis]
• Example language (illustrative): "Your anxiety score has come down two weeks running. What did you do differently this week?"
• Watch for: scores rising early in exposure work, which is normal. [synthesis] Do not reproduce items; use the licensed or published forms.

4.3 Decisional balance

• Purpose: build and keep motivation by weighing the pros and cons of changing against staying the same. [source: NCT04837521 (UP-5 session 1); sobrief summary of TG]
• Steps [synthesis]:
  1. Draw a four-cell grid: benefits and costs of changing; benefits and costs of staying the same.
  2. Have the client fill each cell, prompting for short-term benefits of staying the same, such as the relief avoidance gives.
  3. Reflect on the ambivalence in motivational-interviewing style, without arguing.
  4. Keep the sheet to reuse when motivation dips.
• Example language (illustrative): "Staying as you are has real advantages. You don't have to face the meetings. What does it cost you over a year?"
• Watch for: an empty "costs of changing" cell. That usually signals unvoiced fears about treatment, so explore it. It is working when the client can name what they would lose by not changing.

4.4 Setting treatment goals

• Purpose: turn vague aims into concrete, behavioural steps. [source: NCT04837521: goals are specific and measurable, e.g. "one walk per day"; Trials 2023 table: personal goals set at intake]
• Steps [synthesis]:
  1. Ask for one to three broad goals.
  2. Translate each into observable steps: what you would be doing if things were better.
  3. Order the steps from easier to harder.
  4. Revisit them in Module 8.
• Example language (illustrative): "'Feel less anxious' is hard to see. If anxiety had less say, what would I see you doing on a Tuesday?"
• Watch for: goals framed as removing emotions, such as "never feel nervous". Reframe them as doing things while feeling.

4.5 Psychoeducation: the function of emotions

• Purpose: establish that emotions such as anxiety, fear, sadness and anger are adaptive and carry information and action urges. [source: Sauer-Zavala et al. 2021; NCT04837521; workbook ch. 5 "What Is an Emotion?"]
• Steps [synthesis]:
  1. Ask what anxiety, fear, sadness and anger are for.
  2. Draw out the survival function of each, for example fear driving escape and sadness signalling loss and drawing support.
  3. Contrast "helpful in the right context" with "firing too often or too strongly".
  4. Link this to the client's own episodes.
• Example language (illustrative): "Anxiety is built to get you ready for a threat. The problem isn't that you have it. It's that it shows up loudly when the threat isn't there, and then you fight it."
• Watch for: the client accepting this intellectually while still treating their own emotions as defects. Come back to it in Module 3.

4.6 Three-component model of emotion

• Purpose: break overwhelming emotional experiences into thoughts, physical sensations and behaviours, so they become observable and workable. [source: Sauer-Zavala et al. 2021; Trials 2023 table; NCT04837521]
• Steps [synthesis]:
  1. Take a recent episode and draw three linked circles: thoughts, sensations, behaviours or urges.
  2. Fill each circle from the client's report.
  3. Draw arrows showing how each component feeds the others.
  4. Assign home monitoring of the three components during strong emotions.
• Example language (illustrative): "When you walked into the party, what went through your mind? What did your body do? What did you do, or want to do?"
• Watch for: clients who report only one component, often sensations or "I just felt bad". It is working when entries become specific and separated.

4.7 Following the ARC (antecedents, responses, consequences)

• Purpose: place each emotional episode in context and show how responses maintain distress through short-term relief. [source: workbook ch. 6 title "Following the ARC"; Sauer-Zavala et al. 2021; sobrief summary of TG]
• Steps:
  1. A, antecedents: the trigger, which may be immediate or more distant, such as a poor night's sleep or an earlier argument.
  2. R, responses: thoughts, sensations and behaviours.
  3. C, consequences: short-term (often relief) and long-term (often more distress, fewer opportunities).
  4. The client completes ARC records between sessions.
  5. Review the records for recurring responses that bring short-term relief but have long-term costs. [synthesis]
• Example language (illustrative): "Leaving early worked that night. The anxiety dropped. What did it do to next week's invitation?"
• Watch for: missing distant antecedents. Prompt for sleep, stress and earlier events. It is working when the client spots the relief-then-cost loop without your help.

4.8 Mindful emotion awareness: guided present-focused, nonjudgmental practice

• Purpose: build willingness to notice emotions as they happen, without judging or pushing them away. The skill has two parts: staying focused on the present and observing without judgement. [source: Trials 2023 table; Sauer-Zavala et al. 2021; Psychology Tools TG]
• Delivery: Sauer-Zavala et al. (2021) say clients practise three experiential exercises. Audio-guided practices are used in at least one adaptation. [source: Trials 2023 table]
• Steps [synthesis]:
  1. Explain the two parts: present focus (here and now, not past or future) and nonjudgement (no "good" or "bad" labels).
  2. Run a brief guided practice in session: attend to breath and body, notice thoughts, sensations and urges, label them and return to the present.
  3. Debrief what the client noticed and any judgements that arose.
  4. Assign short daily practice.
• Example language (illustrative): "Just notice the tightness, the thought 'this is too much', and the urge to check your phone. Name each one. You don't need to change any of them."
• Watch for: practice being used as relaxation or to get rid of the feeling. That turns it into avoidance; say so gently. It is working when the client can describe an emotion in its parts without adding self-criticism.

4.9 Mindful mood induction

• Purpose: practise mindful awareness while an emotion is actually present, in a controlled way. [source: Frank & Ritchey 2015, "idiosyncratic emotion induction exercises"; sobrief summary of TG, mood induction with emotion-eliciting music]
• Steps [synthesis]:
  1. Choose material the client finds moving, usually a piece of music, perhaps tied to a memory.
  2. Play it in session and ask the client to observe thoughts, sensations and urges nonjudgmentally.
  3. Debrief: what did they notice, did they judge or try to stop the emotion, and did it change over time?
  4. Repeat at home with other pieces.
• Example language (illustrative): "As the music plays, let whatever comes up be there. Notice it, and notice if part of you wants to switch it off."
• Watch for: distress spilling over in trauma-exposed clients. Choose milder material first. It is working when the client can stay with the emotion and notices it rise and fall.

4.10 Anchoring in the present (incl. a "three-point check")

• [uncertain] These names come from my knowledge of the 2nd edition. No source confirmed them; the sources confirm present-focused awareness only in general terms.
• Purpose: a brief in-the-moment skill. The client uses a cue to come into the present, checks thoughts, sensations and behaviours, and then chooses a response that fits the present situation rather than past worries or future fears.
• Steps:
  1. Pick an anchor cue, such as the breath or a sound.
  2. When emotion rises, attend to the cue.
  3. Do a quick check of thoughts, sensations and behaviours. [uncertain] In the manual this check is called a "three-point check".
  4. Ask whether the response fits what is happening now.
  5. Choose a response consistent with the present moment.
• Example language (illustrative): "Breath first. Then: what am I thinking, what's my body doing, what am I doing? Does that match what's actually happening right now?"
• Watch for: using the anchor as a distraction. It should bring the client into the present, not out of it.

4.11 Identifying automatic appraisals

• Purpose: show that thoughts and emotions influence each other, and catch the fast first interpretation of a situation. [source: Trials 2023 table; NCT04837521; Sauer-Zavala et al. 2021]
• Steps:
  1. Explain the two-way link between appraisals and emotions.
  2. Show an ambiguous picture and ask for the client's first interpretation, then for several more. [source: Frank & Ritchey 2015, "picture of ambiguous valence"]
  3. Point out that the first interpretation came automatically and is only one possibility.
  4. Move to the client's own ARC entries and pull out the appraisals.
• Example language (illustrative): "What's happening in this picture? Okay, what else could be going on? And another?"
• Watch for: clients producing only "right answers" to please you. It is working when they notice appraisals spontaneously in their monitoring.

4.12 Thinking traps

• Purpose: label common habitual appraisal patterns so they are easier to catch. [source: NCT04837521 (habitual, overly negative patterns); Trials 2023 table; sobrief summary of TG]
• The two traps:
  • Jumping to conclusions: overestimating how likely a bad outcome is.
  • Thinking the worst: catastrophising, which includes underestimating one's ability to cope.
• [uncertain] "Thinking the worst" is the label I believe the 2nd edition uses. The secondary summary calls it "catastrophizing".
• Steps [synthesis]:
  1. Define each trap.
  2. Find an example of each in the client's records.
  3. Have the client tag the traps on home ARC forms.
• Example language (illustrative): "'She didn't reply, so she's angry with me.' Which trap is that? And 'If I'm angry at work I'll lose my job and never recover'?"
• Watch for: clients using the labels to criticise themselves ("I'm always catastrophising, I'm hopeless"). Bring nonjudgement from Module 3 back in.

4.13 Generating alternative appraisals (countering questions)

• Purpose: increase flexibility by producing other plausible interpretations, not by proving the original one wrong. [source: Sauer-Zavala et al. 2021; NCT04837521, generating multiple interpretations, "analogous to cognitive restructuring"; sobrief summary]
• Steps:
  1. Take the automatic appraisal.
  2. Ask evidence and probability questions for jumping to conclusions, and coping questions for thinking the worst.
  3. List alternatives.
  4. Hold them side by side and re-rate belief in the original appraisal.
• [uncertain] The manual provides a named question list for each trap; the questions here are not taken from it. Example questions (illustrative): how likely is it, really; what else could explain it; if the worst happened, how would I cope; how have I coped before?
• Example language (illustrative): "We're not trying to find the 'right' thought. Let's just see how many possible stories fit what happened."
• Watch for: reassurance-seeking dressed up as reappraisal, especially in OCD and GAD. Keep alternatives brief and move on. It is working when belief in the original appraisal loosens and the client can tolerate uncertainty.

4.14 Identifying core appraisals (downward arrow)

• [uncertain] The 2nd edition may use a downward-arrow procedure to reach core automatic appraisals; this is unconfirmed.
• Purpose: reach the deeper belief beneath recurring automatic thoughts, for example "I'm incompetent" or "I can't cope".
• Steps [synthesis]:
  1. Start from a hot automatic thought.
  2. Repeatedly ask what it would mean if that were true.
  3. Stop when a global statement about self, others or the world appears.
  4. Apply the alternative-appraisal work at that level.
• Example language (illustrative): "Suppose the boss did think the report was weak. What would that mean about you?"
• Watch for: strong affect as the core belief surfaces. Slow down and use the mindful stance.

4.15 Identifying emotional behaviours

• Purpose: find the client's own behaviours that block full contact with emotion. Short-term relief negatively reinforces them, so they maintain the problem. [source: Frank & Ritchey 2015; Sauer-Zavala et al. 2021; sobrief summary of TG]
• Categories:
  • Overt behavioural avoidance, such as skipping events.
  • Subtle behavioural avoidance, such as avoiding eye contact or caffeine.
  • Cognitive avoidance, such as distraction or thought suppression.
  • Safety signals: objects or people carried "just in case".
  • Emotion-driven behaviours (EDBs): acting on the emotion's urge, such as escaping, checking, lashing out or withdrawing.
• Terminology note: in the 1st edition these were split into emotional avoidance and EDBs. The 2nd edition groups both as "emotional behaviours". [source: Frank & Ritchey 2015 (1st ed.); workbook ch. 9 title]
• Steps [synthesis]:
  1. Teach the categories with the client's own examples.
  2. Go through ARC records and tag each behaviour.
  3. Note the short-term and long-term consequences of each.
  4. Build a personal list.
• Example language (illustrative): "You went to the meeting, so that's not avoidance. But you sat by the door and rehearsed every sentence. What were those doing for you?"
• Watch for: subtle avoidance and safety signals the client doesn't think of as avoidance. The 1st edition stresses telling adaptive EDBs from maladaptive ones. [source: Frank & Ritchey 2015] It is working when the personal list grows to include subtle items.

4.16 Alternative actions (countering emotional behaviours)

• Purpose: replace emotional behaviours with actions that keep contact with the emotion and serve long-term goals. [source: Sauer-Zavala et al. 2021; NCT04837521; Psychology Tools TG]
• Steps:
  1. For each emotional behaviour, identify the urge behind it.
  2. Design an alternative, often the opposite of the urge, for example calling a friend instead of withdrawing. [source: sobrief summary]
  3. Rehearse it in session if possible.
  4. Set a specific home practice: when, where and what.
  5. Record what happened to the emotion and to the consequences. [synthesis]
• Example language (illustrative): "Sadness says stay in bed and cancel. What's the alternative action that goes against that urge, small enough to actually do on Saturday?"
• Watch for:
  • The alternative becoming a new safety behaviour, such as "going but only with my partner".
  • Expecting the emotion to drop straight away.
  • It is working when the client takes the alternative action while the emotion is still present.

4.17 Symptom induction test and interoceptive exposure

• Purpose: deliberately bring on bodily sensations like those of strong emotion. This increases awareness of them, builds tolerance and breaks the link between sensations and fear. It is done even when sensations are not the client's main focus. [source: Sauer-Zavala et al. 2021, which names hyperventilation and thin-straw breathing; Frank & Ritchey 2015; sobrief summary, which adds running in place and spinning]
• Safety and consent (required):
  • Screen first for heart and lung conditions, seizure disorder, pregnancy, asthma, and neck or back injury.
  • Get medical clearance where indicated, and drop or modify exercises accordingly.
  • Explain the purpose, and that the client may stop at any time.
  • Obtain consent before each exercise. [synthesis, standard interoceptive exposure practice]
• Steps:
  1. Run a sampler in session. Use several brief exercises such as over-breathing, straw breathing, spinning, running on the spot, or breath-holding. [uncertain] The full list and durations in the manual were not confirmed.
  2. After each exercise, the client rates intensity of sensation, distress and similarity to natural emotional episodes. [uncertain: exact rating scale not confirmed]
  3. Pick the exercises that are most distressing and most similar.
  4. Repeat them in session and at home, at full intensity, without safety behaviours. Note what the client feared and what happened. [source for full intensity and testing feared outcomes: sobrief summary]
• Example language (illustrative): "We're going to make your heart race on purpose, the same thing that scares you at night. Then notice it with curiosity and let it settle on its own."
• Watch for:
  • Holding back on intensity.
  • Distraction during the exercise.
  • Stopping as soon as discomfort starts.
  • It is working when distress about the sensations falls across repetitions, even if the sensations themselves stay strong.

4.18 Building the emotion exposure hierarchy

• Purpose: list emotionally provoking situations and activities in graded order. [source: Trials 2023 table; Psychology Tools TG and workbook]
• Steps:
  1. Brainstorm situations, images and activities the client avoids or endures with emotional behaviours, across all their diagnoses. [source: NCT04837521]
  2. Rate each for distress and avoidance. [uncertain] The 2nd-edition rating scale was not confirmed; a 0–8 or 0–100 rating works in practice.
  3. Order the items from lower to higher.
  4. Make sure the items cover several emotions (fear, sadness, anger, shame), not anxiety alone. [synthesis]
• Example language (illustrative): "Let's list everything your emotions currently decide for you, from 'a bit uncomfortable' up to 'no way'."
• Watch for: a hierarchy made up only of low items, or items the client can only do with safety signals. Note the safety signals beside each item.

4.19 Conducting emotion exposures

• Purpose: produce strong emotion deliberately and practise all prior skills, learning that emotions are temporary and tolerable. This is where Modules 2–6 come together. [source: Sauer-Zavala et al. 2021; Trials 2023 table]
• Types:
  • Situational (in vivo).
  • Imaginal, such as imagining a feared outcome.
  • Interoceptive.
  • Combinations of these. [source: sobrief summary; Frank & Ritchey 2015 (interoceptive and situational)]
• Consent and safety (required):
  • Plan each exposure collaboratively and agree a stop rule.
  • Screen for current suicidality, active substance misuse, dissociation, and unsafe real-world situations.
  • Never use exposures that create real danger. [synthesis]
• Steps:
  1. Pick an item.
  2. Predict what the client fears will happen and how strong the emotion will be.
  3. Do the exposure, in session first where possible. The client stays with it, notices the emotion mindfully, uses flexible appraisal and drops emotional behaviours.
  4. The therapist gives corrective feedback and blocks subtle avoidance. [source: sobrief summary]
  5. Debrief: what happened compared with the prediction, and what was learned about the emotion.
  6. Assign repeated home exposures and work up the hierarchy.
• Example language (illustrative): "Before you go in, what do you predict? Afterwards, what actually happened, and what did you learn about your ability to have this feeling?"
• Watch for: ending exposures when distress is highest without a debrief, or performing them "perfectly" with hidden safety behaviours. It is working when the client voluntarily approaches higher items and their prediction errors grow.

4.20 Discussing medication

• Purpose: give information on medications for anxiety, depression and related disorders, and how they fit with UP skills. [source: TG ch. 13 and workbook ch. 12 titles, FrancoAngeli TOC and Psychology Tools listing]
• Steps [synthesis]:
  1. Ask about current medication, including any taken as needed.
  2. Explore whether any medication functions as a safety signal, for example carried "just in case".
  3. Refer to the prescriber for any change. Never advise tapering yourself. No dosing guidance is given here.
• Example language (illustrative): "Does knowing the pill is in your bag change what you're willing to do? That's worth talking over with your prescriber."

4.21 Recognising accomplishments and relapse prevention (Module 8)

• Purpose: review progress, consolidate skills and plan continued practice. [source: TG and workbook ch. titles; Sauer-Zavala et al. 2021; NCT04837521]
• Steps:
  1. Compare the progress record and current goals with intake. [synthesis]
  2. List which skills helped most.
  3. Expect ups and downs, and normalise lapses.
  4. Identify early warning signs: returning avoidance or emotional behaviours.
  5. Set long-term goals and a self-practice plan, such as continuing exposures. [source: sobrief summary]
  6. Taper session frequency if possible. [synthesis]
• Example language (illustrative): "You'll still have strong emotions. That's not relapse. The warning sign to look for is you starting to arrange life around avoiding them again."
• Watch for: the client attributing gains only to the therapist. Highlight what they did.

4.22 Group delivery

• Purpose: deliver the UP in groups. [source: TG ch. 15; Arrigoni et al. 2021 (12 online group sessions of about 90 minutes, 8 modules); UP Institute research page]
• Steps [synthesis]:
  1. Use the same module sequence.
  2. Use members' examples to illustrate concepts.
  3. Do interoceptive sampling as a group, with individual safety screening.
  4. Build individual hierarchies, and plan exposures one-to-one or in pairs.
  5. Allow longer sessions.
• Watch for: members comparing diagnoses. Steer back to the shared processes.

5. Handling problems

The 2nd-edition guide includes troubleshooting tips and case vignettes for common obstacles, but their text is not drawn on here. [source: Psychology Tools TG; FrancoAngeli TG preface] Everything below is therefore [synthesis] unless a source is given. It is built from the UP model (aversive reactions to emotion lead to avoidance) and standard CBT practice.

• Low motivation or ambivalence early on.
  • Go back to the decisional balance and the concrete goals (4.3–4.4).
  • Ask what staying the same protects the client from.
  • Reflect ambivalence rather than pushing.
  • Module 1 is about maintaining motivation, so revisiting it mid-treatment is within the model. [source for the title: FrancoAngeli TOC]
• Non-adherence to monitoring or home practice.
  • Analyse the missed practice as an ARC. What was the antecedent? Did the client avoid the form because it brought on emotion?
  • Shrink the task. One ARC a week beats none.
  • Complete a form together in session.
  • Treat avoiding homework as an emotional behaviour to counter, not as a character flaw.
• Stuck: understands the skills but nothing changes.
  • Look for hidden emotional behaviours, especially subtle avoidance, cognitive avoidance and safety signals (4.15).
  • Check whether skills are being used to get rid of emotion, for example mindfulness used as relaxation or reappraisal used as reassurance. That keeps the aversive reaction going.
  • Move to exposure sooner rather than adding more psychoeducation.
• Overwhelm during mood induction, interoceptive work or exposure.
  • Do not abruptly end on a peak and leave. Ground the client in the present (4.8, 4.10), then debrief.
  • Next time, step down the hierarchy rather than abandoning exposure.
  • Separate tolerable high distress (expected) from loss of safety: dissociation, panic about harming self, intoxication.
  • For loss of safety, pause the exposure work and assess.
• Dissociation or trauma flooding.
  • Start with milder induction material.
  • Shorten exposures and add grounding before and after.
  • Consider whether a trauma-focused protocol should come first or alongside. [uncertain: the UP has been applied to PTSD, but sequencing guidance is not described]
• Suicidal ideation or self-harm.
  • Assess risk at intake and whenever depression scores rise, using standard structured risk assessment.
  • Make a collaborative safety plan, and use lethal-means counselling about storage and removal.
  • Suspend high-intensity exposures during acute risk.
  • A five-session UP has been described as acceptable for adults with acute suicide risk. [source: NCT04837521, citing prior work; risk procedures not described there]
• Reassurance-seeking disguised as cognitive work (OCD, health anxiety, GAD).
  • Limit reappraisal to generating alternatives once.
  • Do not review the evidence repeatedly.
  • Name repeated questioning as an emotion-driven behaviour.
• Client wants only one problem treated.
  • Show how the same feel-it, judge-it, avoid-it loop runs in their other problems, using their ARCs.
  • If they still decline, weight the hierarchy towards their priority while keeping the core modules.
• "Physical sensations aren't my problem." Explain why Module 6 is still done: sensations are part of every emotion, and tolerating them reduces avoidance in general. [source: Frank & Ritchey 2015, module completed even when sensations are not a focus] Use the most emotion-relevant exercises.
• Medical concerns about interoceptive exercises. Screen and get clearance (4.17). Use milder substitutes for contraindicated exercises, and never push past a medical stop.
• Alliance ruptures, such as feeling pushed during exposure or criticised by the "avoidance" label.
  • Name the rupture and own your part.
  • Return to shared goals.
  • Revisit consent and the pace of the hierarchy.
  • Use nonjudgmental language about avoidance: it made sense and it worked short-term.
• Depression-dominant clients who feel little emotion.
  • Emphasise alternative actions that counter withdrawal (4.16).
  • Use sadness- and shame-focused exposures, not only anxiety items.
• Group-specific issues.
  • For members who dominate or compare diagnoses, use structured go-rounds and anchor discussion in shared processes.
  • Hold one-to-one check-ins for anyone not engaging with exposures.
• Time pressure (fewer sessions available).
  • Deliver all core modules briefly rather than dropping any. A five-session version exists. [source: NCT04837521]
  • Prioritise exposure time.

Sources

Sources

• Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide (2 edn), Oxford Academic (metadata only)
• Il protocollo unificato per il trattamento transdiagnostico dei disturbi emotivi: Guida per il terapeuta, FrancoAngeli demo PDF (Italian translation of the 2nd-ed. TG: contents, preface, ch. 1)
• Psychology Tools: UP 2nd ed. Therapist Guide listing
• Psychology Tools: UP 2nd ed. Client Workbook listing
• Unified Protocol Institute: Research
• Sauer-Zavala et al. (2021). Skill acquisition during transdiagnostic treatment with the Unified Protocol. Behavior Therapy 52(6)
• Frank & Ritchey (2015). Unified Protocol training slides, American College of Psychiatrists
• NCT04837521 protocol: Five Session Unified Protocol for Older Adults
• Trials (2015) 16: Table 1, UP modules and sessions
• Trials (2023): Table 1, UP-based programme sessions
• Arrigoni, Marchena-Consejero & Navarro-Guzmán (2021). Revista Costarricense de Psicología 40(2)
• Book summary of the UP Therapist Guide (secondary)

Books cited

• Barlow, D. H., Sauer-Zavala, S., Farchione, T. J., Murray-Latin, H., Ellard, K. K., Bullis, J. R., Bentley, K. H., Boettcher, H. T., & Cassiello-Robbins, C. (2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide (2nd ed.). Oxford University Press.
• Barlow, D. H., et al. (2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Workbook (2nd ed.). Oxford University Press.
• Barlow, D. H., et al. (2011). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide (1st ed.). Oxford University Press.

Further reading (not drawn on) [uncertain]

• The job's key sources: the BU repository item (permission timed out) and the UTS meta-analysis record.
• The full manual text.