Empirically-supported treatment-tailoring

Many of us like to think we perform a careful assessment and then match our treatments to the processes that keep a problem going or that are needed for the client to reach their goal. However, empirical support that this approach is superior to simply allocating a treatment based on diagnosis or problem is very scant. That’s why I’m especially excited by this week’s article from Sauer-Zavala and colleagues (2019) on the latest study developing Barlow and colleagues Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders.

The Unified Protocol consists of modules designed to target transdiagnostic skill deficits in emotion regulation that are common maintaining factors of many problems including: anxiety disorders, depressive disorders, bipolar disorder and borderline personality disorder. The modules and the skills they were designed to build are presented in the table below, along with the measure the authors used to assess the ability at baseline.

Table for Unified Protocol.jpg

This was a small study of 12 people: 6 with Generalised Anxiety Disorder, 2 with Social anxiety disorder, 2 with Obsessive Compulsive Disorder, 1 Major Depressive Disorder and 1 Other Trauma Disorder. It used a replicated single-case design where everybody has a 2-week baseline followed by a treatment phase (i.e., AB design). However, a cool feature was that clients were assessed for their strengths and weaknesses in the five skills at baseline, and then randomized to one of two sequences of the same 5 modules: From greatest strength to greatest weakness or weakness to strength. Thus, it formed a mild test of “capitalising” versus “compensating” strategies for treatment.
One of the first questions was whether differences in emotion regulation abilities would be clear enough to be the basis of allocation to a treatment sequence. Nine of the 12 participants showed significant differences between their greatest emotion regulation strength and weakness at baseline (equivalent to a 1.96-point difference in z-scores). So, this looks like a worthwhile exercise.
The study wasn’t expecting to find differences between groups post-treatment because by that point everyone would have received the same set of modules. However, participants who received modules addressing their strengths before progressing to their weaknesses experienced reduced anxiety and depression sooner (by an average of about 1.5 sessions earlier) than those whose modules concentrated on weaknesses first. This replicated a previous study looking at modular CBT for depression (Cheavens et al., 2012).

Although we need to be cautious about assuming the results will generalise to other samples, the principles demonstrated in this small study would be safe for clinicians to emulate. This kind of study seems well suited to replication using other profiles of strengths and weaknesses (the authors had trouble differentiating skill in emotion exposure from overcoming behavioural avoidance with the measures they used).

Take-home: Clinical Implications

Most clients will have variability in their emotion regulation skills that will allow you to discriminate strengths and weaknesses

  • Getting your clients to reengage with ways they have successfully regulated their emotions in the past and increasing their use of these and related skills should lead to quicker improvement in anxiety and depression than starting with their least developed areas of emotion regulation

  • (At least within the broad areas of CBT covered by the Unified Protocol for anxiety and depression) Psychoeducation about the purpose that emotions serve and how avoidance worsens emotional problems is best done in the earliest treatment session. Thereafter, modules covering different skills in a treatment plan can be individually-sequenced without loss of effectiveness.


Go to https://journals.sagepub.com/doi/full/10.1177/0145445518774914 for the original article.

References

Cheavens, J. S., Strunk, D. R., Lazarus, S. A., & Goldstein, L. A. (2012). The compensation and capitalization models: A test of two approaches to individualizing the treatment of depression. Behaviour Research and Therapy, 50, 699-706. doi:10.1016/j.brat.2012.08.002

Sauer-Zavala, S, Cassiello-Robbins, C, Ametaj, AA, Wilner, JG & Pagan, D 2019, ‘Transdiagnostic Treatment Personalization: The Feasibility of Ordering Unified Protocol Modules According to Patient Strengths and Weaknesses’, Behavior Modification, vol. 43, 4, pp. 518–543.

Matthew Smout