Treating a Cluster of Internalizing Disorders With the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: A Case Study

Abstract

Psychotherapy outcome research rarely focuses on the ideographic application of treatment manuals, though some modules might prove markedly more important for a client than others. Clients in need of psychoeducation, emotion regulation skills, and changes in maladaptive patterns of thinking might balk at portions of the Unified Protocol for the Treatment of Emotional Disorders that seem irrelevant to their concerns. The current case study focused on emotion dysregulation and perfectionism given their role in anxiety, depression, obsessions, and compulsions. The Overall Anxiety Severity and Impairment Scale (OASIS), Overall Depression Severity and Impairment Scale (ODSIS), and Yale-Brown Obsessive Compulsive Scale (Y-BOCS) confirmed qualitative reports and therapist observations of improvement. Additional sessions focused on fostering self-compassion and processing the termination of a romantic relationship rather than completing every section of the manual. This case demonstrates that flexible adaptation of a transdiagnostic treatment manual, in conjunction with a strong working alliance and other non-specifics of therapy, can produce beneficial outcomes even when other modules are not applied. These results might support ideographic application of select modules from treatment manuals and support a symptoms approach to psychotherapy.

Keywords

transdiagnostic unified protocol emotional disorders

1. Theoretical and Research Basis for Treatment

Transitioning to independent living in college brings about numerous stressors, including academic struggles, relationship problems, and worry about future career prospects. These stressors covary with psychopathology, especially anxiety and mood disturbances (Beiter et al., 2015). In 2015, of students who sought professional mental health care, approximately 16% presented with anxiety and 13% presented with depression (American College Health Association, 2015). While only 5% of students meet diagnostic criteria for obsessive-compulsive disorder (OCD), subthreshold symptoms of OCD are also prevalent among this population and covary with elevated anxiety (Sulkowski et al., 2011). These conditions are often comorbid, potentially due to similar underlying mechanisms. Examples of these transdiagnostic mechanisms include perfectionism and emotion dysregulation (Egan et al., 2011; Sauer-Zavala et al., 2012). A lack of self-compassion might also contribute to the development and maintenance of internalizing disorders (MacBeth & Gumley, 2012). Given links between psychopathology and negative sequalae including substance use, poor academic performance, and suicidal behaviors, access to mental health treatment on college campuses is necessary to mitigate potential adverse outcomes (Becker et al., 2018; Pedrelli et al., 2015).

Cognitive-behavioral therapy (CBT), which targets the complex interplay between thoughts, emotions, and actions, is a first-line treatment for internalizing disorders. Disorder-specific CBT appears effective for individuals with internalizing disorders (Watts et al., 2015). While disorder-specific CBT has the potential to effectively treat psychopathology, transdiagnostic CBT, which treats multiple disorders by focusing on common underlying mechanisms, might be superior for comorbid diagnoses, due to easier implementation (Craske, 2012; Norton et al., 2013). The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a cognitive-behavioral, emotion-focused manual targeting shared mechanisms underlying internalizing disorders (e.g., depression and anxiety), such as emotion dysregulation and perfectionism (Barlow et al., 2011; Sauer-Zavala et al., 2012). A recent meta-analysis confirms the UP’s potential to reduce dysfunction due to internalizing disorders with large effect sizes (Hedge’s g range: −1.60 to −.99; Sakiris & Berle, 2019). The UP also appears to reduce symptoms of OCD, although continued work with larger samples is necessary (Saed et al., 2016). Treatment gains from the UP appear to be maintained over time; individuals treated with the UP demonstrate small increases in anxiety and moderate increases in depression from 6- to 12-month follow-up (Bullis et al., 2014). Although transdiagnostic CBT and disorder-specific CBT might yield similar outcomes, one study evidenced reduced attrition using the UP (Barlow et al., 2017). Thus, the UP might be an effective alternative to traditional disorder-specific CBT for internalizing disorders.

Treatment success may also improve with an emphasis on common, non-specific factors of therapy. The non-specifics of therapy, otherwise known as common factors, include variables such as the therapeutic alliance and client outcome expectancies (Laska et al., 2014). These factors play important roles in treatment outcomes with small but meaningful effect sizes (Cameron et al., 2018; Constantino et al., 2011). The UP’s modular format facilitates flexible adaptation, allowing treatment to satisfy clients’ specific needs (Barlow et al., 2011). Previous case studies highlight how clinicians can adapt the UP to focus on each client’s most pressing concerns (Donahue et al., 2019; Mian et al., 2020). This flexibility enhances the therapeutic alliance by promoting goal consensus and active therapist-client collaboration. Through early discussion of treatment rationale and explanation of the program outline, the UP also fosters development of positive client outcome expectancies. Positive pre-treatment beliefs about the effectiveness of the UP covary with beneficial treatment outcomes (Sauer-Zavala et al., 2018). Given the effectiveness of transdiagnostic treatments, and their ability to enhance the nonspecific components of therapy, the UP is an appropriate treatment option for college students with internalizing pathology.

Still, deviations from standardized treatments to address other variables can be beneficial. Self-compassion, an individual’s capacity to express kindness and practice non-judgment toward oneself, might represent an important treatment target for individuals with anxiety and depression (Neff, 2003). A meta-analysis of the relation between self-compassion and psychopathology (e.g., depression and anxiety) indicates a moderate negative effect (r = −0.54; MacBeth et al., 2012). Individuals high in self-compassion report fewer symptoms of anxiety and depression (Hoge et al., 2013; Krieger et al., 2013). Scores on self-compassion assessments aid in the prediction of depressive and anxious psychopathology (Van Dam et al., 2011). Data support the addition of self-compassion work as an adjunct to CBT for symptoms of depression, anxiety, and trauma (for a review, see Stefan & Hofmann, 2019). Nevertheless, these studies did not employ randomized controlled trial designs to assess for differences compared to a treatment as usual (TAU) condition. Despite this caveat, increasing self-compassion might be an appropriate treatment addendum for individuals with internalizing disorders.

2. Case Introduction

In accordance with clinic policies and procedures, and to ensure the client’s anonymity, identifying details about the present case have been changed. All general information regarding the client’s assessment, diagnosis, and treatment remains unchanged. “Victoria” is a 19-year-old, single, Asian-American, female, second-year college student. She was referred to a psychological training clinic by a university psychiatrist for symptoms of depression, anxiety, and obsessive-compulsive disorder (OCD). The therapist was a second-year clinical psychology doctoral student practicing under the supervision of a licensed clinical psychologist.

3. Presenting Complaints

During her initial telephone intake, Victoria disclosed multiple stressors leading her to seek treatment. Victoria experienced increased symptoms of anxiety and depression during the middle of her second year of college. These symptoms included racing thoughts, persistently low mood, difficulty concentrating, and insomnia; these symptoms persisted for approximately 6 weeks. Victoria indicated that her symptoms significantly impacted her academic functioning (e.g., diminished ability to complete assignments and reduced focus in class), as she was getting less than 3 hours of sleep per night. These symptoms continued until Victoria checked herself into a hospital because of her sleeping concerns. Victoria was prescribed hydroxyzine, an antihistamine with anxiolytic properties, to help her facilitate sleep. Despite using this medication for several days, Victoria did not notice a demonstrable change in her symptoms and was referred to a psychiatrist. Victoria was prescribed lorazepam (a benzodiazepine used to alleviate anxiety) and fluoxetine (a selective serotonin reuptake inhibitor with antidepressant effects) to be used daily. Although these medications reduced some of Victoria’s symptoms (e.g., excessive crying and insomnia), her psychiatrist urged her to engage in psychotherapy as well.

During this time of heightened anxiety and depression, Victoria noticed a resurgence of more severe symptoms of OCD with obsessions centered around perfectionism. Since high school, Victoria experienced mild symptoms of OCD, such as organizing her locker until it was “just right” and re-circling answers on multiple choice exams up to fifteen times. At that time, those symptoms did not significantly interfere with Victoria’s life. More recently, Victoria reported clicking her pencil obsessively, arranging items on her desk for “abnormal amounts of time,” and making excessive to-do lists. These symptoms interfered with Victoria’s academic performance, as she was unable to complete exams in the allotted time. As a result, Victoria sought academic accommodations for extended time on assignments. To be eligible for these accommodations in future semesters, Victoria’s university required documentation from a mental health care provider.

4. History

Victoria belonged to a small immediate family, consisting of two parents and one younger sister. Both of Victoria’s parents immigrated to the United States from China. Victoria described her parents as “typical immigrant stereotype helicopter parents.” Victoria reported that they held very high expectations of their children. Victoria attributed her own work ethic and perfectionistic tendencies to her demanding upbringing. Growing up, Victoria reported a strained relationship with her parents. Early on, Victoria recalled that her parents were unsupportive and dismissive of her mental health struggles. Victoria reported that her parents believed mental health issues were signs of weakness and reflected poorly on the family unit; consequently, they suggested Victoria deal with her concerns privately to avoid social shame. However, after Victoria’s hospitalization, her parents appeared to become more understanding and compassionate. They accepted Victoria’s decision to seek psychological services and provided her with transportation for appointments. Victoria believed her relationship with her parents substantially improved due to these circumstances.

Victoria also described having a distant relationship with her younger sister, noting that she “bullied” her sister growing up. Much like with her parents, Victoria noted that her relationship with her sister improved since the onset of her mental health difficulties. Furthermore, Victoria disclosed that her sister had also been diagnosed with OCD, with obsessions centered around contamination. To her knowledge, Victoria and her sister were the only two family members that experienced these symptoms or any mental health concerns. Victoria did not note any relationships with other family members beyond her parents and sister.

In high school, Victoria maintained decent friendships with peers whom she felt could relate to her overprotective parents. In addition to spending several hours per day studying and doing homework, Victoria also reported being involved in numerous clubs, including an honor society, a math club, and a volunteer organization. Victoria endorsed experiencing symptoms of both anxiety (e.g., racing thoughts and difficulty concentrating) and depression (e.g., low mood and sleep difficulties) at the time. Additionally, she noticed her first symptoms of OCD, including spending long periods of time organizing her locker and circling answers on exam keys until she felt they were “perfect circles.” Despite having a supportive group of friends, Victoria feared social stigma and was unable to share with her friends about her mental health concerns. Similarly, Victoria did not seek mental health services at that time, as she did not believe her concerns significantly impacted her functioning.

Victoria reported that she struggled upon entering college. Despite developing several friendships, Victoria noted that her relationships centered around sports, such as running and basketball. These relationships became strained as Victoria’s mental health problems worsened. Victoria also reported a shift in her academic achievements. While Victoria excelled in high school, she struggled to manage her workload and meet the high standards at her prestigious university. With a major in biomedical engineering and a minor in statistics, Victoria reported feeling overwhelmed by the academic rigor of her courses. Victoria often compared herself to her peers, and considered her performance inferior to theirs; this led to a decrease in her self-esteem. Victoria also struggled to complete assignments on time because she wanted them to be “just right.” This ultimately led to poorer grades. Due to these changes in her academic performance, Victoria noticed an increase in her mental health symptoms. Overall, this combination of events led Victoria to consider leaving university.

Victoria also described having an intimate relationship with a male partner, whom she had been dating for several months at the time of her intake appointment. Victoria’s partner was initially very supportive of her. He would talk through all of Victoria’s concerns and transported her to the hospital at the peak of her anxiety and depression. During the course of treatment, this relationship ended as Victoria’s partner felt he could no longer deal with her symptoms, including irritability and reassurance-seeking. Initially, the termination of this relationship worsened Victoria’s mental health concerns. Nevertheless, over time, Victoria acknowledged she was able to move on from the relationship and suggested she would be interested in pursuing other romantic relationships in the future.

Upon her initial assessment, Victoria reported that she had overall good physical health. She reported receiving semi-annual physical exams with her primary care doctor. At her most recent physical, Victoria’s doctor reported no physical health concerns. When she was less stressed, Victoria endorsed engaging in regular physical activity, such as running and playing basketball, and eating a balanced diet. Presently, Victoria indicated that she was engaged in less physical activity, felt lethargic more often, and had a decreased appetite. Victoria attributed these changes to her mental health and did not believe they were indicative of any medical concerns.

Victoria reported a history of hyperthyroidism. At her most recent physical, her thyroid levels were within the acceptable range and thus appeared unlikely to contribute to her presenting concerns of anxiety and depression. Victoria also disclosed a history of childhood cancer. While Victoria did not provide many details about her history with cancer, at the time of her treatment she reported being in remission. According to therapist judgment of Victoria’s current stressors as well as Victoria’s report, there was no indication that Victoria’s history of cancer influenced her present psychological symptoms. Victoria reported no history of substance abuse or misuse, although she reported trying alcohol in college. Victoria’s only psychiatric hospitalization occurred shortly before beginning treatment. Victoria reported no lifetime history of suicidal or homicidal ideation.

5. Assessment

Initial Assessment

Victoria presented for two intake assessment appointments, a 2-hour long session and a 1-hour long session. Over the course of her intake sessions, Victoria was screened with the Mini International Neuropsychiatric Interview Version 7.0 (MINI; Sheehan et al., 2015). The MINI is a validated diagnostic interview used to assess for the presence of DSM-recognized psychological disorders. Across numerous studies, the MINI demonstrates strong psychometric properties, including excellent inter-rater reliability and convergent validity with other similar assessments, such as the Composite International Diagnostic Interview (CIDI) and the Structured Clinical Interview for DSM-IH-R (SCID; Lecrubier et al., 1997; Sheehan et al., 1998). The assessment is also well-tolerated by patients (Pinninti et al., 2003). The MINI is often used as an alternative to more costly and time-intensive diagnostic interviews.

During administration of the MINI, Victoria met criteria for generalized anxiety disorder (GAD; current), obsessive-compulsive disorder (OCD; with good or fair insight), and major depressive disorder (MDD; recurrent episode, moderate, with anxious distress, moderate) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013). Victoria endorsed the following symptoms consistent with GAD: excessive worry about routine things, difficulty regulating worries, restlessness, lethargy, difficult concentrating, irritability, and difficulty sleeping. Despite the intermittent presence of these symptoms since high school, at intake, Victoria stated that these symptoms were present most days in the past 6 months. These symptoms impeded her academic performance and hindered her friendships.

Victoria also reported the following symptoms consistent with an OCD diagnosis: recurrent distressing thoughts with attempts to control them, excessive urges to perform behaviors repeatedly in response to obsessions, and significant distress associated with these obsessive thoughts and compulsive behaviors. Similar to her anxiety symptoms, Victoria’s symptoms of OCD had persisted since high school; however, at that time, she did not recognize her symptoms as indicative of OCD, nor did they cause significant functional impairment.

Furthermore, Victoria reported symptomology consistent with MDD, including feeling down nearly every day for 2 weeks, decreased interest in previously enjoyed activities, insomnia, being more fidgety than usual, feelings of worthlessness, fatigue, and difficulty concentrating. Victoria’s most recent depressive episode occurred approximately a month prior to her seeking services. Since starting medication, Victoria’s depression symptoms appeared to improve (e.g., elevated mood and decreased frequency of crying spells); nevertheless, according to her report, Victoria’s mood had not yet returned to its “normal” level.

Victoria’s mental status was also assessed via behavioral observations. Initially, she had trouble maintaining eye contact, appeared fidgety, and sat on the edge of her seat. Victoria spoke softly but quickly, fearing she would forget something. Her presentation in therapy appeared consistent with the symptomology she described. Victoria was consistently oriented to person, place, and time and her memory appeared to be intact. Based on Victoria’s educational attainment and verbal abilities, she appeared to be of at least average or above average intelligence. Moreover, Victoria appeared to have good insight about her difficulties and was open to sharing them. Victoria denied any instances of lifetime or present hallucinations, delusions, and suicidal or homicidal ideation.

Both the Overall Anxiety Severity and Impairment Scale (OASIS; Norman et al., 2006) and the Overall Depression Severity and Impairment Scale (ODSIS; Bentley et al., 2014) were administered to evaluate baseline levels of anxiety and depression. These 5-item self-report measures assess severity of symptoms across a 1-week span, with higher scores indicating greater impairment.

Both the OASIS and ODSIS have demonstrated strong psychometric properties, including internal reliability and convergent validity (Bentley et al., 2014; Bragdon et al., 2016; Campbell-Sills et al., 2009). Victoria’s pretreatment scores on the OASIS and ODSIS were 12 and 12 respectively, indicating moderate to severe levels of anxiety and depression. The therapist also administered the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989) to assess pre-treatment OCD. The Y-BOCS evaluates the occurrence and severity of obsessions and compulsions and interference with daily functioning. Previous work validates the strong psychometric properties of the Y-BOCS, including excellent internal reliability and good convergent validity (Woody et al., 1995). Victoria’s baseline Y-BOCS score of 23 signified moderate OCD. These measures were administered at regular intervals (weekly for the OASIS and ODSIS, biweekly for the Y-BOCS) to assess treatment progress.

Diagnosis and Differential Diagnoses

While the aforementioned diagnoses appeared to explain Victoria’s symptoms, several differential diagnoses were considered. Adjustment disorder with mixed anxiety and depressed mood might have explained Victoria’s initial symptoms upon her transition to college; however, Victoria’s symptoms persisted beyond 6 months after this transition. These symptoms also intensified in Victoria’s third semester of college. Similarly, Victoria noted that some of her anxiety and depressive symptoms preceded her enrollment in college, making adjustment disorder unlikely. Persistent depressive disorder (dysthymia) was also considered due to Victoria’s report of sustained depressive symptoms since high school. Although Victoria described persistent feelings of low self-esteem and fatigue, she also recalled periods longer than 2 months where these symptoms were mostly absent; thus, this diagnosis did not apply.

Being that Victoria experienced numerous physiological anxiety symptoms (e.g., a racing heart and difficulty breathing), the therapist closely assessed for panic disorder. While Victoria reported that she experienced “anxiety attacks” previously, they often lasted longer than 10 min and were precipitated by identifiable triggers (e.g., school exams and out-of-place objects). Victoria did not report any fear about future panic attacks, nor did she significantly alter any of her behaviors to avoid future attacks. As such, panic disorder was not applicable.

The therapist also considered diagnoses of anxiety disorder and/or mood disorder due to medical conditions, given Victoria’s history of childhood cancer and hyperthyroidism. Both conditions positively covary with anxiety and depression (Ittermann et al., 2015; Linden et al., 2012). However, the onset and resolution of Victoria’s medical concerns predated the recent aggravation of her psychiatric symptoms, making a causal link unlikely. This hypothesis is bolstered by a recent annual physical, with no unusual findings.

6. Case Conceptualization

The therapist conceptualized Victoria’s presenting complaints through a cognitive-behavioral framework. Specifically, Person’s (2012) cognitive-behavioral case formulation promoted an understanding of the client’s symptoms by examining their origins, current precipitants, proposed causal mechanisms, and maintaining factors. A combination of biopsychosocial factors likely influenced Victoria’s present functioning. The goal of this conceptualization is to develop a coherent case history used to inform effective treatment.

Developmental

From a young age, Victoria recalled her parents modeling a “strong work ethic” and “high standards.” Victoria carried these perfectionistic tendencies into her adolescent and adult life. Beginning in high school, both Victoria and her sister evidenced their first symptoms of OCD. Previous work suggests a strong genetic contribution of OCD, where first-degree relatives of individuals with OCD are at higher risk (Browne et al., 2014). Both Victoria’s developmental history and genetics might have contributed to her anxiety and OCD symptoms.

Victoria’s early relationships might also have influenced her present functioning. As a child, Victoria reported distant relationships with her parents, in part due to their work schedules. Consequently, she might have developed an anxious-ambivalent attachment style. Bowlby’s (1980) theory of attachment states that children with anxious-ambivalent attachment styles may become overly dependent upon parents who are preoccupied with other responsibilities. Individuals with anxious attachment styles are at heightened risk for anxiety and depression and tend to seek comfort and safety in their adult relationships, especially when provoked by external stressors (Mikulincer & Shaver, 2012; Simpson & Steven Rholes, 2017). Perhaps due to her early attachment experiences with her parents, Victoria developed an anxious-ambivalent attachment with her romantic partner, whereby she constantly sought out his reassurance and physical presence during times of heightened anxiety and depression. These findings underscore how Victoria’s developmental history might have influenced her current functioning.

Cognitive

According to Beck’s cognitive theory, schemas enable individuals to quickly process their environments (Beck, 1976). Due to Victoria’s perceived failure to meet her parents’ standards, she may have developed a negative self-schema. This schema manifested in maladaptive thoughts about herself and her potential. Victoria’s cognitive distortions included “all-or-nothing thinking,” “over-catastrophizing,” and “discounting the positives.” These maladaptive thoughts raced through Victoria’s mind during overwhelming bouts of anxiety. As a result, Victoria believed she was unable to think rationally or make informed decisions. These cognitions likely contributed to and exacerbated Victoria’s anxiety and depression.

Social

In high school, Victoria maintained a group of mainly Asian-American friends, whom could relate to her struggles with her parents. Despite having many friends, Victoria never spoke of her mental health concerns for fear of stigmatization. Victoria’s social support dwindled in college; Victoria believed this was due to her low desire to use substances. Victoria reported having three close friends, including her romantic partner. Her platonic friendships centered around sports, which she stopped playing due to her depression. Additionally, midway through treatment, Victoria’s partner terminated their romantic relationship. As such, Victoria experienced social isolation, potentially aggravating her anxiety and depression (Wang et al., 2018).

Behavioral

To cope with feelings of hopelessness and inadequacy, Victoria engaged in compulsive rituals including list-making and organizing objects until they were in the “right” position. These behaviors temporarily decreased Victoria’s anxiety by giving her a sense of control. These behaviors are consistent with Mowrer’s (1939) twostage theory of fear and avoidance development and maintenance in OCD. Victoria’s compulsive thoughts about her academics and her health were pervasive. To avoid dealing with these painful thoughts, Victoria engaged in ritualistic behaviors to momentarily decrease her anxiety, ultimately maintaining her avoidance and likely increasing her suffering in the long run. These behaviors are also consistent with experiential avoidance, whereby individuals attempt to avoid uncomfortable thoughts and emotions, even when doing so creates harm (Hayes et al., 1996).

Victoria also engaged in other non-ritualistic avoidant behaviors, such as lying in bed, ignoring friends, and neglecting previously enjoyed activities (e.g., running and basketball). Depression can manifest through reductions in positive reinforcement from environmental stimuli (Ferster, 1973). Depressed individuals also perform avoidant behaviors, perpetuating this lack of positive reinforcement. Although avoidance might temporarily relieve distress, it precludes the individual from reengaging with positive stimuli. As Victoria withdrew from positive activities and engaged in avoidant behaviors, her depression was exacerbated.

Maintaining Factors

Victoria exhibited low self-compassion, which likely perpetuated her psychopathology. Self-compassion refers to taking a non-judgmental approach to one’s own suffering by providing inward kindness during difficult times (Neff, 2003). Previous work suggests a lack of compassion covaries with increased mental health concerns (r = −0.54; MacBeth and Gumley, 2012). Victoria often judged her own inner experience and felt isolated in her mental health struggles. By neglecting kindness for herself, Victoria likely exacerbated her symptomatology.

Strengths

Victoria’s insight and above average level of intelligence facilitated her treatment progress. She identified connections between her thoughts and behaviors. This helped her rectify her maladaptive thought patterns and modify unhelpful behaviors. Victoria was also highly motivated to attend treatment and implement positive changes. Victoria attended nearly all sessions on time and only missed one homework assignment due to an academic obligation.

Victoria also exhibited resiliency on several occasions, likely enhancing her treatment outcomes. Victoria was a childhood cancer survivor. When asked to identify her strengths during a self-compassion exercise, Victoria noted that her ability to withstand chemotherapy and beat cancer made her mentally stronger. Additionally, Victoria noted that the termination of her romantic relationship increased her self-reliance and perseverance. Taken together, Victoria’s personal strengths and resiliency likely contributed to her treatment success.

Numerous vulnerabilities in conjunction with present stressors likely played a role in Victoria’s impaired functioning. The UP was chosen to address core processes underlying Victoria’s comorbid anxiety, depression, and OCD diagnoses. Additionally, the therapist opted to include a self-compassion module into treatment due to Victoria’s lack of inward kindness and her rigid and demanding personal standards.

7. Course of Treatment and Assessment of Progress

Upon completion of her initial psychosocial evaluation, Victoria completed nine 1-hour individual psychotherapy sessions over the course of 3 months. Victoria attended all scheduled sessions and did not cancel any appointments. Sessions broadly followed the UP. Given the UP’s modular format, amendments were easily accommodated. Treatment add-ons included a self-compassion module and processing of the client’s break-up with her partner.

Phase 1: Rapport Building and Psychoeducation

Initial intake sessions established a working alliance. After reviewing clinic policies and procedures, Victoria appeared apprehensive about completing standardized assessments, for fear of leaving out important details. The therapist initiated an informal conversation about Victoria’s presenting concerns and treatment goals using motivational interviewing skills. Motivational interviewing (MI) is used to help clients resolve ambivalence and increase self-efficacy while enhancing the therapeutic alliance (Miller & Rollnick, 2013). Core skills of MI include asking open-ended questions, using reflections, and affirming client’s strengths. CBT plus MI can increase treatment effectiveness (Arkowitz & Westra, 2004). Using MI, the therapist reflected Victoria’s concerns and normalized her experience. The therapist assured the client that she could expand on her answers or ask questions at any point. This modification tailored treatment to better meet Victoria’s needs, likely enhancing the alliance.

Initial appointments also addressed psychoeducation about emotional disorders (e.g., anxiety and depression) and their treatment. Victoria initially expressed some distress around feeling alone in her struggles. She also believed she was inferior to other students who were excelling in their academic studies unencumbered by mental health issues. These feelings were bolstered by Victoria’s cultural background as an Asian-American, where many people in her community perceive mental illness as weakness or laziness. While the therapist validated Victoria’s feelings of isolation, she also provided information about the prevalence of anxiety and depressive symptoms in college students to help normalize her experience. Similarly, the therapist elicited Victoria’s feelings about how her ethnicity and family background influenced her perception of mental illness. By engaging in this discussion, the therapist gained valuable information regarding how culture impacts this client’s understanding of her own suffering and used it to inform future sessions.

Phase 2: Unified Protocol

Sessions two through five adhered to the unified protocol (UP). First, the therapist and client established treatment goals, using the UP’s template for goal-setting. Victoria identified two main treatment goals: learning to effectively manage stressful situations and identifying thought patterns which influence behavior. Discussions focused on making these goals more manageable by breaking them down into smaller steps. The therapist and client also discussed how to identify meaningful progress toward those goals. The purpose of this activity was to increase Victoria’s awareness of what she wanted to achieve from therapy.

After identifying treatment goals, the therapist provided psychoeducation about the function of emotions. After discussing the three-component model of emotions (e.g., the link between thoughts, emotions, and behaviors), the therapist and client discussed associations between Victoria’s emotions and behavior. Victoria noted that she often acted impulsively in response to fear and sadness, leading Victoria to catastrophize scenarios or engage in ritualistic behaviors. The therapist normalized this behavior for the client by providing a physiological explanation of how stress can trigger “flight-or-fight” responses in the body. For homework, Victoria monitored the antecedents and consequences of her emotional behaviors using a UP worksheet. This assignment was discussed in subsequent sessions to increase Victoria’s awareness and prompt discussion about adaptive stress-response strategies.

The next two sessions were devoted to discussing cognitions and the influence of emotions on thoughts. First, the therapist presented the Ambiguous Picture from the UP and asked the client to give her automatic appraisal of the situation. Victoria identified her immediate reaction to the picture as negative. After being asked to consider alternatives, Victoria generated other explanations for the scenario. This activity helped Victoria understand the power of negative automatic appraisals and their influence on thought patterns. The Downward Arrow Technique was also used to help Victoria understand her core automatic appraisals of situations in her life (e.g., “What would happen if X were true? What would it mean about me?”).

Additionally, the therapist and client discussed thinking traps. Victoria often engaged in “jumping to conclusions,” “all or nothing thinking,” and “catastrophizing.” The therapist introduced the concepts of cognitive reappraisal and cognitive flexibility to promote more rational thinking. To engage these concepts, Victoria was asked to provide evidence in support of or against her thoughts and weigh the evidence to determine their validity. Victoria noted that her emotions influenced her ability to think rationally. Homework assignments supplemented these in-session exercises; Victoria monitored her thoughts nonjudgmentally, identified thinking traps, and generated alternative cognitions outside of sessions.

The dyad also completed modules related to avoidance and emotion-driven behaviors (EDBs), which are behavioral responses that individuals engage in to alleviate extremes in affect (Barlow et al., 2011). After the therapist explained the different types of avoidance strategies (e.g., subtle behavioral avoidance, cognitive avoidance, and using safety signals), Victoria noted that she often engaged in cognitive avoidance to cope with stress. When Victoria used distraction strategies (e.g., watching television and listening to music), her distressing thoughts intensified and lasted longer. To combat these cognitions, Victoria performed behaviors to decrease her emotional arousal, such as turning to her partner for emotional support. These behaviors often alleviate short-term distress, but are maladaptive when used long-term. The dyad identified the function of Victoria’s EDBs, as well as the benefits and consequences. To counter these behaviors, Victoria generated a list of alternative actions to engage in when feeling compelled to perform an EDB (e.g., socializing with friends, exercising, or sitting with anxious feelings). For homework, the client monitored her EDBs and practiced using alternative actions instead.

Though the UP contains three more modules related to bodily sensations, emotional exposure, and psychiatric medications, the therapist opted to exclude these modules. While these topics were not allocated specific time in sessions, they often came up in discussions. For example, Victoria expressed concern about her physiological reactions to anxiety (e.g., dizziness, accelerated heart rate, and difficulty breathing). These bodily sensations related to the client’s reactions to her emotions during the initial UP sessions. These symptoms decreased over the course of treatment, diminishing the relevance of the bodily sensations module. Given time constraints on Victoria’s treatment due to the training clinic’s nature, the therapist prioritized other interventions. The flexible, modular format of the UP allows for such adaptations to best serve the client; thus, three sessions deviated from the UP and instead focused on processing the client’s relationship termination and a self-compassion module (Neff & Germer, 2018).

Phase 3: Processing of Relationship Termination

Victoria initially reported a romantic relationship with a male college student, whom she described as supportive and understanding. Midway through treatment, Victoria’s partner terminated their relationship, reportedly due to Victoria’s neediness. Although Victoria had made significant progress in treatment, this stressor increased Victoria’s reports of depression and anxiety symptoms. In the session following the breakup, Victoria cried and expressed doubt about her ability to proceed with her academics. The therapist used supportive listening skills and conveyed empathy. As Victoria spoke about her relationship, she processed her experience using her learned therapeutic skills (e.g., replacing distorted cognitions with more rational thoughts). Victoria also developed a list of self-care activities to perform during this difficult time. Despite self-reported elevations in anxiety and depression, Victoria left the session visibly brighter than when she entered. In subsequent sessions, Victoria’s mood and outlook on the breakup continued to improve.

Phase 4: Self-Compassion

Near the end of treatment, the therapist completed a two-session module on self-compassion with the client. Victoria consistently expressed that she was too rigid about her unrealistic personal standards. Self-compassion appears to play a role in the link between transdiagnostic processes and symptoms of internalizing disorders (Ferrari et al., 2018; Finlay-Jones, 2017). Thus, the therapist incorporated material from the Mindful Self-Compassion Program (Neff & Germer, 2013). First, the therapist administered the Self-Compassion Scale (SCS; Neff, 2003). The SCS is a 26-item measure assessing how individuals act toward themselves during difficult times. Victoria scored high on items related to self-judgment and low on self-kindness items. Victoria recognized that her responses could be linked back to her cognitive distortions, such as “catastrophizing” and “all-or-nothing thinking.” After discussing this link, the therapist provided some psychoeducation about self-compassion and the importance of displaying kindness toward oneself and enhancing one’s own mindful non-judgment.

Later work was dedicated to increasing Victoria’s self-compassion. The therapist provided examples of activities to increase self-compassion, including thinking about how Victoria might treat a friend going through a difficult time and using a self-compassion journal (Neff & Germer, 2018). The dyad also generated strategies Victoria could use to increase her self-compassion, such as acknowledging her strengths and accomplishments and engaging in self-care. The therapist provided Victoria with her baseline SCS scores and a blank copy to complete in the future as she strived toward being more self-compassionate.

Phase 5: Termination

Due to the nature of the university training clinic, a termination date was set upon Victoria’s initial assessment. While Victoria expressed concern about only working with her therapist for a short time, she proceeded with treatment. Occasionally, discussions centered around Victoria’s desire to proceed with treatment after the therapist’s departure. A transfer request was made upon termination to address Victoria’s OCD and maintain her current progress. Despite this, Victoria did not proceed with psychological services at the training clinic.

Victoria’s final session was dedicated to processing termination. Discussion focused on assessing progress and identifying developed skills. Victoria identified the most useful aspect of therapy as learning how to be present-focused, allowing her to better monitor her thoughts and feelings. The dyad discussed potential obstacles that Victoria might face in the future and which skills would best suit those situations. Victoria also completed the OASIS, ODSIS, Y-BOCS, and WAI-S. The therapist provided feedback about Victoria’s progress by sharing the results of her assessments and the therapist’s clinical observations. Finally, the therapist acknowledged the client’s dedication to treatment and wished her continued success.

Progress Monitoring and Outcome Assessment

Victoria’s progress was assessed weekly with the OASIS and ODSIS; her scores on both decreased during treatment (see Figure 1). Victoria’s baseline scores of 12 on both measures indicated moderate to severe anxiety and depression. Scores above 8 are indicative of probable anxiety and depressive disorders (Bentley et al., 2014; Campbell-Sills et al., 2009). After her intake assessment, Victoria’s scores on both measures decreased until a spike at week 6, due to her relationship termination. From week 7 on, Victoria’s symptoms appeared to improve. Her post-treatment scores of 5 on both measures indicate sub-clinical levels of symptoms, and a 58.3% reduction in Victoria’s symptoms of anxiety and depression from baseline to post-treatment.

Figure 1.

Line graph assessing changes in Victoria’s self-reported symptoms of anxiety and depression as measured by the Overall Anxiety Severity and Impairment Scale (OASIS) and the Overall Depression Severity and Impairment Scale (ODSIS), respectively.

The Y-BOCS was also administered biweekly to examine changes in OCD symptoms; Victoria also showed reductions in these symptoms throughout treatment (see Figure 2). At baseline, Victoria’s score of 23 on the Y-BOCS indicated moderate OCD. Despite steady scores early on, Victoria’s Y-BOCS score was 14 at termination, demonstrating a 39.13% reduction in OCD symptoms from pre- to post-treatment. This change in diagnostic severity from moderate to mild suggests that Victoria experienced decreases in symptoms, despite treatment not focusing specifically on OCD. This improvement might be explained by treatment targeting transdiagnostic mechanisms underlying Victoria’s diagnoses (e.g., emotion dysregulation and perfectionism).

Figure 2.

Line graph assessing changes in Victoria’s self-reported obsessive-compulsive disorder (OCD) symptoms as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).

Additionally, the therapeutic alliance was measured via the Working Alliance Inventory-Short Form (WAI-S; Tracey & Kokotovic, 1989). This 12-item measure assesses the therapeutic alliance across three domains. The strength of the therapeutic alliance covaries with treatment outcomes (Cameron et al., 2018). Administration of this measure occurred during the fourth session and termination. According to Victoria’s endorsements, she reported a strong working alliance with the therapist across the three subscales at both time points. Victoria highly endorsed all three subscales of the WAI-S, including goal consensus (26/28), task agreement (25/28), and bond strength (24/28). No changes in scores were noted across time points.

Victoria also verbally endorsed therapeutic gains. Victoria reported enjoying therapy and having a space to talk about her experiences. While Victoria still experienced anxiety and depressive symptoms, she found them to be more manageable when using her learned skills. Victoria also reported being better able to monitor her cognitions, identify thinking traps, and alter irrational beliefs. While Victoria was initially skeptical about the benefits of therapy, she was now convinced of its merit based on her improvements.

Therapist observations also confirmed Victoria’s treatment success. During initial sessions, Victoria presented as quite nervous and seemed hopeless about her academic future. Throughout treatment, Victoria appeared to relax; she maintained better eye contact and slowed her rate of speech. She also began to speak of her future more optimistically. By termination, Victoria appeared excited and spoke about summer internships. She became reacquainted with her friends, reengaged in hobbies, and spoke about pursuing a new romantic relationship.

8. Complicating Factors

Cultural incongruence between Victoria and her provider might have yielded unintended outcomes and alliance ruptures. Upon enrolling in treatment, Victoria endorsed that her cultural background influenced the way she conceptualized mental health. Victoria, a first-generation American citizen, reported that her parents held negative beliefs toward mental health concerns and treatment. Many Asian-Americans, especially those foreign-born, share these perceptions around mental health treatment; this stigma might contribute to their underutilization of services (Kramer et al., 2002; Meyer et al., 2009). Potentially due to her family’s cultural beliefs, Victoria did not enroll in treatment until her symptoms were very severe. Earlier enrollment in treatment might have provided Victoria with faster symptom relief and prevented prolonged suffering.

Victoria’s academic obligations might also have impacted her treatment progress and outcomes. Victoria’s enrollment in five rigorous courses may have hindered her ability to practice skills outside of therapy sessions. As such, Victoria’s progress might have been stalled due to her lack of time. On one occasion, Victoria was unable to complete her assigned homework due to schoolwork. Nevertheless, Victoria did not consistently miss homework assignments; thus, the therapist did not dedicate much time to addressing this issue.

9. Access and Barriers to Care

Initially, Victoria’s parents were unsupportive of her treatment. Victoria believed her parents were ashamed of her mental health concerns; they feared social stigmatization if others found out that their daughter was enrolled in therapy. Through psychoeducation and open communication about treatment goals between Victoria and her parents, Victoria’s parents ultimately supported her treatment. Although this issue was resolved fairly quickly, lack of family support can diminish treatment effectiveness or lead to premature attrition.

Two other barriers related to Victoria’s access to transportation and finances. Victoria did not have access to a vehicle for transportation. Additionally, due to her student status, she did not hold a job, impacting her ability to pay for sessions. Although Victoria qualified for the lowest session fee, she could not afford her sessions. Victoria relied upon her family to transport her to sessions and finance her treatment. Despite these barriers, treatment was only minimally impacted. On two occasions Victoria was slightly late to sessions; both times she was apologetic, and treatment proceeded as usual. Victoria was also unable to provide immediate payment for two sessions as she had forgotten to collect money from her parents. She paid her outstanding balances upon subsequent sessions and treatment appeared to remain unaffected. Had these issues continued or worsened, treatment might have been more heavily influenced.

10. Follow-Up

Upon termination with the present writer, Victoria requested to be transferred to another therapist at the university training clinic. Although the therapist completed transfer paperwork, Victoria did not follow through with continued care. Alternatively, Victoria might have pursued treatment with an external provider.

11. Treatment Implications of the Case

This case highlights how the flexible use of a transdiagnostic intervention can be applied to a treatment naïve young woman who met criteria for GAD, MDD, and OCD. The UP targeted shared underlying mechanisms of these diagnoses in an effective and efficient manner. Over the course of treatment, qualitative and quantitative reports evidenced substantial improvements in Victoria’s symptomology and overall functioning. Despite not specifically targeting the client’s OCD, continued progress monitoring revealed decreases in these symptoms, highlighting the benefits of transdiagnostic interventions. Flexible adaptation of the UP allowed for the client’s needs and preferences to be prioritized. Modules not applicable to this client were replaced with sessions dedicated to processing her relationship termination and increasing self-compassion. Additionally, specific considerations were warranted to respect and accommodate the client’s ethnic background. By using a client-centered approach to Victoria’s treatment, the working alliance was likely strengthened, potentially leading to enhanced treatment outcomes.

12. Recommendations to Clinicians and Students

When treating individuals with comorbid diagnoses, using transdiagnostic manuals can effectively minimize client burden and maximize treatment gains. Although strict adherence to manuals might be effective for some clients, flexibly adapting treatments can more directedly meet individuals’ therapeutic needs. Ideographic approaches allow clinicians to focus on the non-specifics of therapy, which play important roles in treatment outcomes. By applying a more personalized treatment approach, clinicians can also better explore the role of clients’ cultural backgrounds and modify treatment to address cross-cultural factors. In conjunction, routine outcome assessment can aid in the individualization of treatment by informing treatment adaptations. Using a flexible, evidence-based approach to a transdiagnostic intervention allows therapists to effectively tailor treatment to best serve their clients.

Footnotes

Authors’ Note

Both authors were affiliated with the University at Albany, State University of New York Psychology Department during the treatment of this case and preparation of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Brianna R. Altman

Author Biographies

Brianna R. Altman, MA, is a clinical psychology doctoral student at the University at Albany, State University of New York (SUNY). She received her bachelor’s of arts from George Washington University and her master’s of arts from the University at Albany, SUNY.

Mitch Earleywine, PhD, is a professor at the University at Albany, State University of New York (SUNY). He earned his PhD in Clinical Psychology from Indiana University and completed his doctoral internship at the University of Mississippi Medical Center. Prior to starting at the University at Albany, SUNY, Dr. Earleywine was an assistant professor and associate professor at the University of Southern California.

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