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BABCP spring meeting: David Barlow's unified protocol - motivation enhancement & treatment rationale (third post)

I wrote yesterday about the one day workshop I went to with David Barlow introducing "Unified protocol for the treatment of emotional disorders".  David described an eight module sequence for anxiety, depression and potentially other problems too:

1.) Motivation enhancement for treatment engagement (1/2 to 1 session).
2.) Psychoeducation & treatment rationale (1 to 3 sessions).
3.) Emotional awareness training (1 to 3 sessions).
4.) Cognitive appraisal & reappraisal (1 to 2 sessions).
5.) Emotion driven behaviours & emotional avoidance (1 to 3 sessions).
6.) Awareness & tolerance of physical sensations (1 session).
7.) Interoceptive & situational emotion exposure (4 to 6 sessions).
8.) Maintenance & relapse prevention (1 session).

In today's post I'd like to make a few comments about the first two modules.  I think most of us attending this workshop might have been a little surprised at the Unified Protocol's routine use of Motivation Enhancement for pretty much all clients coming for treatment.  I certainly had Motivation Enhancement filed in my mind as a tool to use just occasionally for obviously ambivalent clients and possibly more frequently when working with substance abuse and other health behaviour challenges.  David highlighted two phases in this process - building motivation and enhancing self-efficacy.  The latter he felt was dealt with fairly well with goal setting (see later).  For the former - building motivation - he suggested that as a therapist one should acknowledge that amibivalence over whether to try to change or not is natural, express empathy for this situation, develop & sharpen discrepancy, and "roll with resistance".  We were given a simple client handout with four spaces for writing in the pros/benefits and cons/costs both of changing and of staying the same.  This material reminds me both of the Self-Determination Theory research on the importance of supporting intrinsic, self-chosen motivation (see handouts on the "Wellbeing, time management & self-determination" page of this website) and of the value of "Mental contrasting".  We were also shown a goal setting form used in the Unified Protocol sequence.  The very reasonable suggestion is that setting oneself clear, specific, personally important treatment goals makes progress easier - the targets are identified and concretely described in terms of what one will be doing and not doing differently when one has achieved the progress one most wants to make.  These key goals are then broken down into steps - subgoals that are each likely to be reachable with a few days up to maybe a month or so's work.  It feels very "behavioural", in the sense that clients are strongly encouraged to make the steps to their major treatment goals very much about actions rather than about thoughts and emotions.  Interesting and probably a very important point.  It has the same flavour as behavioural activation for depression or Acceptance and Commitment Therapy for a wide variety of psychological disorders.  Mazzucchelli et al's recent paper "Behavioral activation interventions for well-being: A meta-analysis" shows how effective this action-based approach can be for promoting happiness as well as decreasing distress.

Possibly, in this one day workshop, we went over the next "Psychoeducation and treatment rationale" module a little too quickly.  For a cognitive behavioural therapist I think it's important to go back and look at what's "written on the tin" here.  This treatment is called "Unified protocol for transdiagnostic treatment of emotional disorders".  In the recently published "Client workbook", Barlow & colleagues write "This treatment was developed following several decades of research into how anxiety and mood disorders develop ... our research draws from the science of psychopathology, the science of emotion, neuroscience or the science of the brain, and the science of human behavior."  Note "draws from ... the science of emotion ... " not "cognitive science".  And I think this is right.  The protocol links much more for me with a connected but different research tradition from classic cognitive science as I understand it.  On this website, see a whole series of relevant posts including the neuroscientist & emotion-advocate "Antonio Damasio's 'Self comes to mind': overview", "The 'bus driver' is warm-blooded: integrating mindfulness & emotion", "Reappraising reappraisal""Oregon university research on emotional regulation" and especially "Stanford psychophysiology lab research on emotional regulation".  Fascinating territory.  Also highly relevant is the long string of research papers on the importance of the ability to delay short-term gratification for longer term benefit - see, for example, "A gradient of childhood self-control predicts health, wealth, and public safety" and "'Willpower' over the life span: decomposing self-regulation."

A key link between the benefits of being able to delay gratification (not being "seduced" by the short term pull of pleasant emotions) and the benefits of being able to tolerate/regulate unpleasant emotion (not being "bullied" by the short term avoidance of unpleasant emotions) is seeing emotions not as positive or negative, but as adaptive/functional or maladaptive/dysfunctional.  Both pleasant and unpleasant emotions may be adaptive; both pleasant and unpleasant emotions may be maladaptive.  It's about context and what serves key, personal, major, longer term priorities.  As Barlow et al's "Client workbook" reads "At their core, all of these (emotional) disorders arise out of a tendency to experience emotions more frequently, more intensely, and as more distressing than someone without these disorders".  Being bullied by, amplifying, and striving to avoid these short term unpleasant emotions is a common theme across emotional disorders ... just as being seduced by, amplifying, and having one's life ruined by striving to maximise short term pleasant emotions is a common theme across many addictions, broken relationships, antisocial behaviour, and stunted achievement.  As is usually the case, we're talking about a spectrum across the whole population here.  And pretty much all of us would benefit from doing a better job with managing the pull of short-term gratification.  See the post "Common sense isn't common" with its comment "The vast majority of us know that we should eat sensibly, be a reasonable weight, exercise regularly, not abuse alcohol, and avoid smoking. Do you know what percentage of people actually follow all this obvious advice? A survey (Reeves and Rafferty 2005) of over 153,000 US adults in 2000 found that only 3% ticked all four boxes when asked if they didn’t smoke, were a healthy weight (body mass index, calculated as weight in kilograms divided by square of height in meters, 18.5 to 25.0), consumed 5 or more portions of fruit and vegetables daily, and exercised in leisure time for at least 30 minutes, 5 or more times per week (this includes brisk walking)".  I don't want to be boringly puritanical here.  Savouring, enjoying, appreciating good experiences definitely contribute to wellbeing, but only contribute.  Research suggests that meaning & engagement trump pleasure as wellbeing promoters ... see the post "The spectrum of mental health: moderate & full wellbeing".

See the further blog post "Emotional awareness training & cogntive reappraisal" for a description of the next two modules in the eight module "Unified protocol" intervention.


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