Dimensions of skill use in the unified protocol: Exploring unique effects on anxiety and depression.

Abstract

Objective: Although the Unified Protocol contains multiple distinct skills to target anxiety, depression, and related conditions, researchers have yet to establish if patients' use of these skills contributes to symptom change. Using data from the first-stage randomization of a sequential multiple assignment randomized trial, we tested whether general skillfulness, defined by skill knowledge, frequency, quality, and effectiveness, predicted within-or between-person changes in anxiety and depression. We further tested whether use of particular UP skills (e.g., mindfulness and behavior change) predicted changes in these outcomes. Method: Participants (N = 70; M age = 33.74, 67% female, 74% white) completed six sessions of core UP modules and reported on their skillfulness and specific skill use using two novel measures, along with their symptoms of anxiety (Overall Anxiety Severity and Impairment Scale) and depression (Overall Depression Severity and Impairment Scale) before each session, and their alliance (Working Alliance Inventory) after each session. We disaggregated between-from within-person effects to test the effects of skillfulness, skill use, and the alliance on session-to-session symptom change. Results: Greater within-person skillfulness predicted decreases in anxiety and depression. More frequent within-person use of all UP skills predicted decreases in anxiety, whereas more frequent within-person use of alternative actions specifically predicted decreases in depression. Conclusions: This pattern of results provides guidance on the specific aspects of skill training to prioritize in transdiagnostic treatments depending on whether therapists are targeting anxiety or depression.What is the public health significance of this article? For people with anxiety and depressive disorders being treated with the Unified Protocol, using therapy skills more skillfully and more frequently than normal predicts decreases in anxiety. Using therapy skills more skillfully and specifically using alternative actions to avoidant urges more frequently than normal predicts decreases in depression.

The effects of the Unified Protocol and Unified Protocol skills on loneliness in the COVID‐19 pandemic

“…Finally, using more UP skills than one's personal average predicted session‐to‐session decreases in loneliness. Changes in loneliness were not predicted by the frequency of general or specific UP skill use, in contrast to previous findings regarding anxiety and depression (Southward & Sauer‐Zavala, 2022 ). Importantly, by including anxiety and depression as covariates, these results suggest that the effect of UP skill quantity is relatively specific to loneliness and not anxiety or depression.…”

“…The Unified Protocol Skill Use Scale (UPSUS; Southward & Sauer‐Zavala, 2022 ) is a 7‐item self‐report measure designed to assess the frequency of UP skills use. Each item describes core skills taught in the core UP modules.…”

“…Although the effects of the UP on loneliness are unclear, researchers have demonstrated that using the therapeutic strategies taught in the UP more frequently, effectively, and in line with how they were taught predicts decreases in anxiety and depression (Southward & Sauer‐Zavala, 2022 ). Skill use can be operationalized along several dimensions, including frequency, number of skills, and the specific skills used (Southward et al, 2021 ), each of which may be uniquely related to symptom changes (Southward & Sauer‐Zavala, 2022 ). Testing the effects of these dimensions on loneliness could identify which should be prioritized in treatment.…”

“…Among patients in the UP who used maladaptive responses (e.g., self‐blame, denial, substance use) more often at baseline, those who used adaptive strategies (e.g., acceptance, cognitive reappraisal) more frequently over treatment reported decreases in anxiety and depression (Conklin et al, 2015 ). Similarly, using UP skills more frequently predicted decreases in anxiety but not depression (Southward & Sauer‐Zavala, 2022 ). Because loneliness often co‐occurs with anxiety and depression (Danneel et al, 2020 ), frequency of skill use is a plausible dimension of change.…”

“…Specific skills (e.g., mindfulness, behavior change) have been also associated with decreases in anxiety and depression. In the UP, acting opposite to urges to avoid emotional behaviors (i.e., Countering Emotional Behaviors) more frequently predicted decreases in depression (Southward & Sauer‐Zavala, 2022 ). Researchers have suggested that mindfulness (Veronese et al, 2021 ) and cognitive restructuring (Käll et al, 2020 ) may effectively reduce loneliness, though these conclusions are supported by relatively few randomized controlled trials, none of which tested the UP.…”