The Unified Protocol

the unified protocol

What is the unified protocol for the transdiagnostic treatment of emotional disorders?

It is a transdiagnostic, cognitive-behavioral therapy that focuses on emotions for the treatment of various emotional disorders like depression, anxiety, Obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

The unified protocol is a mechanistically transdiagnostic
treatment of emotional disorders. This means that it was developed
by singling out the psychological processes that underlie the emotional

The unified protocol utilizes the three main components of
the ‘negative affect syndrome’ which are:

  • Recurrent and severe adverse assumptions or
  • Powerful reaction to the adverse affect
  • Substantial avoidance or evasion of the

The unified protocol, therefore, targets the underlying susceptibilities of emotional disorders. This is unlike other methods that target the diagnostic category.

Treatment rationale for the unified protocol

There is a high level of comorbidity between depression and
anxiety. This includes OCD and PTSD.

76% of people suffering from one of the two emotional
disorders will be affected by the other over the life span of the disorder.

It is also noted that the treatment of either depression or anxiety yields an improvement in the symptoms of the other. To this effect, anti-depressants are very effective in treating several emotional disorders including anxiety disorder.

In the current medical climate, there exists a number of disorder-specific treatment (therapy). However, this makes the treatment of diagnostically heterogeneous patients very hard for clinicians.

It is also taxing to disseminate each disorder-specific
treatment for each of the huge number of emotional disorders. Therefore, a broadly
applicable and scientifically proven treatment for emotional disorders helps
the clinicians so much because it is easier to disseminate.

What is the theory behind the unified protocol treatment rationale?

Results from several studies indicate the commonalities that
are seen in most emotional disorders. The unified protocol focuses not on the similarities
rather than differences of the emotional disorders.

An example of similarities in anxiety disorders is the worry. This is seen for example in worry about safety in GAD, worry that you will get another panic attack in panic disorders among others.

Most of the emotional disorders seem to respond positively
to a broad treatment regime. For example, anti-depressants work for both
anxiety disorders and depression.

The triple vulnerabilities theory that transdiagnostic
treatment focuses on include:

  • Recurrent and intense adverse affect that is felt as aversive.
  • Bias in handing the emotion in the mind. Individuals with emotional disorders judge their feelings negatively. For example, a person may judge themselves as weak because they experience anxiety.
  • There is a tendency to have behavioral avoidance or suppressive behaviors.
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Emotions play a huge role in the incidence and continuance of anxiety disorders, depression, and related disorders.

Therefore, focusing on the three major vulnerabilities play a huge role in the treatment of these disorders. The unified protocol was born out of the cutting-edge research on these vulnerabilities.

What makes-up the Unified Protocol?

The unified protocol consists of the following cores skills:

  • Challenging the thoughts towards internal and
    external threats and facilitating evaluation and being flexible in cognitive
  • Identifying and changing the challenging emotional
  • Intensifying awareness and forbearance of
    physical feelings via interoceptive exposures
  • Participating in emotional exercises

Nurturing mindful awareness

This involves having a present and indulgent consideration
of emotions. This is an important and central skill in unified protocol. This
is because it forms the basis of using the other core skills.

Unified Protocol thus stresses the need for more tolerance of
emotions since they are flexible and functional.

While using this core skill, UP uses mindfulness exercises
in session. These short-term day-to-day exercises helps to ensure the awareness
becomes present-focused.

In the session the patient is encouraged to identify the feelings, thoughts, and behaviors that result from the unfriendly emotions. Then the mindfulness exercises are used to enable you to be more tolerant and non-judgmental to the emotions.

Challenging the thoughts towards internal and external threats and facilitating
evaluation and being flexible in cognitive appraisals

This applies components of the existing Aaron Beck’s cognitive
therapy to help in ‘probability overestimation’ and ‘catastrophizing’.

‘Probability overestimation’ is the process that occurs in
emotional disorders like anxiety disorder where the likelihood of a negative incident
happening is magnified.

‘Catastrophizing’ on the other hand is amplifying the
results of the negative incident if the event happens in addition to
underestimating your capacity to cope.

In unified protocol, the patient is given help to be cognitively flexible and rational rather than putting an end to the adverse thoughts or even replacing them. Being flexible helps in emotion regulation. Patients are given review skills and strategies to be used before, during, and after high-emotion moments.

Identifying and changing the challenging emotional behaviors

Emotional behaviors are the regular reactions from the
emotional situations.

Having this core skill as part of unified protocol results
from scientifically proven theories that show that it is effective in emotional

The core skills developed in this strategy help you in minimizing forms of avoidance. This avoidance may be behavioral, cognitive, or safety signals.

This is focused on as early as possible when treatment is started
and given more impetus as the treatment program continues. This is done by being
able to see the differences in adaptive and maladaptive behaviors that are as a
result of emotions.

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After identification, the strategy enables you to gain
adaptive behavioral reactions to any stimuli.

The strategy, therefore, helps you to feel different every time you get the emotional stimuli.

Intensifying awareness and forbearance of physical feelings via interoceptive

The emotional disorder patients are requested to engross
themselves in a succession of interoceptive exercises that are made to induce bodily
feelings that are similar to what they feel when uncomfortable in an emotional

These interoceptive exposures have been used for panic
disorder treatment for some time. For this action the physical sensations are met
which are both the disorder stimuli and also the precise nucleus for the

In unified protocol, the interoceptive measures are not as singular
treatment of a disorder. It is applied across several disorders.

The action is used in disorders where physical sensations are or are not the trigger for the emotional reaction. This helps you to become aware and tolerate the physical sensations. The result is minimizing or controlling avoidance and aversion behaviors enabling you to cope.

All patients are made to understand how somatic feelings impact
thoughts and behaviors broadly.

Participating in emotional exercises to bring together all core treatment models

This involves interoceptive and situational exposure to
emotional experiences. The exposures are done in a progressive way like in
other CBT models. Progressive exposure enables a patient to face less demanding
situations before facing more difficult situations that provoke stronger emotions.

Interoceptive exposures help in recognition and tolerance of
the unpleasant physiological feelings that are connected with emotional

Situational exposures enable a person to agree with emotional
experiences that result from external stimuli.

With each progressive exposure, the patient is supposed to tackle the situation completely. This way the therapist is able to minimize or eliminate any avoidance or evasion behaviors to the exposure.

The patient is able to achieve new learnings and create fresh memories. The process of creation of the new learnings and memories can be replicated by patients to adapt to any stressful situation.

Unified protocol modules

The unified protocol can track its basis from cognitive-behavioral
therapy approaches. As in the traditional CBT approaches, the unified protocol
has several modules whose base is the emotions.

The modules focus on increasing awareness of interaction and the function of the model of emotion components which include thoughts, physical sensations, and behaviors. The final bit of the unified protocol is to change the components to a present moment awareness.

The unified protocol is used to treat different emotional
disorders unlike the traditional CBT approaches. This is done by targeting the underlying
mechanisms that form part of all emotional disorders.

The 5 core skills above are delivered to patients through five
core modules.  Before the key modules,
there are 2 modules for introduction and learning about emotions.

After the 5 core modules there is a module for treatment
progress appraisal and making plans to prevent relapse.

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The unified protocol modules are as follows:

  • Module 1: Setting the treatment goals and
    motivation augmentation
  • Module 2: Using psychoeducation to learn the
    function of emotions and their development
  • Module 3: Mindful (present-focused and non-judgmental)
    emotional awareness- Core module
  • Module 4: Cognitive flexibility- Core module
  • Module 5: Identifying and countering emotional avoidance
    behaviors- core module
  • Module 6: Increasing awareness and confronting
    physical sensations/ interoceptive sensitivity- core module
  • Module 7: Both situational and interoceptive emotion-focused
    exposures- Core module
  • Module 8: Recognizing accomplishments and
    looking to the future (relapse prevention)

All the modules layer on each other to ensure the learnings
improve the patient’s wellbeing. These modules are carried out by following the
laid down sequence.

The modules are covered in a session or in several sessions
depending on the patient’s needs. All the modules have to be completed to
ensure a better prognosis.

Emotional disorders treated with the Unified Protocol

Unified protocol was developed to treat all anxiety
disorders in addition to unipolar mood disorders. The approach targets the
underlying factors that lead to emotional disorders.

This differentiates unified protocol from specific-disorder protocols that focus on the specific emotional disorder symptoms like worries, obsessions, panic attacks, nausea, chest pain among others.

Some of the anxiety disorders that have been successfully treated using unified protocol according to several studies include:

  • Panic disorders
  • Agoraphobia
  • Generalized anxiety disorder
  • Obsessive-compulsive disorder
  • Social anxiety disorder/ Social phobia
  • Post-traumatic stress disorder

Other emotional disorders that have been treated with the
unified protocol are:

  • Unipolar depressive disorders
  • Other emotional disorders

It should be noted that several of the disorders listed
above might be present in the same patient. The unified protocol because of its
basis enables the treatment of co-morbid disorders.

Advantages of the unified protocol over single-disorder protocol

The treatment offers a simultaneous solution for comorbid conditions
at a comparatively similar effectiveness to single-disorder protocols.

Unified protocol reduces the burden of training because rather
than having several single-disorder protocols, UP targets several disorders.

Studies also show that UP has a marginally better therapy completion
than Single-Disorder Protocols


According to a study the
unified protocol markedly improves the quality of life in people suffering from
emotional disorders. This is associated with the reduction of symptoms of emotional

The unified protocol is a mechanistically approach that targets the underlying factors that lead to the incidence and maintenance of emotional disorders. This, therefore, leads to an improvement in co-morbid disorders and also means its applicable to treat several disorders.

In comparison to the single-disorder protocols, the unified protocol offers a relatively easier training process for the treatment of emotional disorders and thus can be used effectively in resource-constrained environments.

To read more on the unified protocol, kindly get the book the Unified Protocol for the transdiagnostic Treatment of Emotional Disorders or join the unified protocol institute.

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