Robert D. Friedberg, Ph.D., ABPP, ACT rfriedberg@paloaltou.edu Beyond alphabet soup: The need for transdiagnostic and unified CBT protocols for youth Robert D. Friedberg, Ph.D., ABPP, ACT rfriedberg@paloaltou.edu

Agenda No alphabet soup for you: Why we need transdiagnostic unified approach Unified approaches Modular CBT MATCH-ADTC Unified Protocol for Youth

Alphabet Soup CBT for Dep CBT for OCD CBT for GAD CBT for PTSD CBT for SAD CBT for SOP

Why we need Transdiagnostic CBT for youth Co-morbidity Caseloads of practitioners typically reflect severe co-morbidity and consequently they do not invest in single disorder protocols Complicated family circumstances (Chu, 2012) Targeting core mechanisms and common pathways increase possibility of generalization (Chu, 2012, Chu & Ehrenreich- May, 2013). Increased clinical flexibility (Chu & Ehrenreich-May, 2013)

Transdiagnostic approach A transdiagnostic approach offers a comprehensive treatment package Integrated interventions target multiple problems; solves the multiple manual problem Transdiagnostic and unified protocols may better serve dissemination and training

Transdiagnostic approach Based on (chu, 2012) Shared etiology Common pathways Similar maintaining processes

Common pathways to disorders (Chu & Ehrenreich-May, 2013 Cognitive Attention Memory Intolerance of uncertainty (Dugas & Ladouceur, 2000) Perception of control Thought suppression Rumination Perfectionism

Common pathways Emotional Interpersonal Community/Sociocultural Hi Negative affect, low positive affect Experiential avoidance Interpersonal Family conflict Peers Community/Sociocultural Neighborhood influences Broader societal forces

Attentional pathways Diagnostic group Attentional pathway Panic Catastrophic misinterpretation of normal bodily sensations Social anxiety Fear of negative evaluation, embarassment, scrutiny OCD Intrusive thoughts regarding responsibility for harm PTSD Hypervigilance to threat cues and reaction to past trauma GAD Vigilance to range of dangers, consequences of worrying Eating Dis Overconcern with body weight and shape Depression Overconcern with worth and acceptability

Memory Intrusive memories common to PTSD Social Phobia Agoraphobia Body Dysmorphic Disorder Bipolar Disorder Major Depressive Disorder

A potential useful algorithm Dudley, Kuyken, & Padesky, 2011 Transdiagnostic UP’s are useful when Single Disorder that is Not otherwise specified (NOS) or does not match protocol’s parameters Two or more co-morbid conditions

Modules and manuals Chorpita, Daleiden, & Weisz, 2005 Manuals Specifies therapy content Operationalizes therapeutic procedure Specify a sequence to the operations Supports adherence checks Proliferation of many manuals with a select few disorders

Modules Modules Distill discrete techniques from manuals Combine different techniques into conceptual categories based on shared common elements Creates meaningful units that have relationship between them

Modules Modules allow practitioners to make better use of outcome data Can be responsive to individual variations Diagnosis Age Ethnicity Gender

MATCH-ADTC Weisz & Chorpita (2012) Modular Approach to Therapy with Children and Adolescents with Anxiety, Depression, Trauma, and Conduct Problems Like a library of procedures Complete with flow charts, clinician guidance systems, scripts, materials, dashboard monitoring systems

MATCH-ADTC: Some components Brief description of procedure Recommendation for individual/family Goals of procedure Materials needed Prompts for therapists Scripts Prompt to end session on positive note (“Leave em laughing”)

Examples of core procedures by problem area Fear ladder Anx, Trauma Active ignoring Conduct Exposure Problem solving Depression Trauma narrative Trauma Psychoeducation Anx, Dep, Trauma, Conduct Pleasant activity scheduling Correcting cognitive errors

MATCH-ADTC: Clinical Information System Yields Brief Problem Checklist which reports on “top” problems identified by parents (Chorpita et al., 2010) May also use broader measures such as the CBCL and/or the Stengths and Difficulties Questionnaires Records which modules were used and their effectiveness

Unified protocol for youth Components of the UP (Ehrenreich-May & Bilek, 2012) Three common principles Altering antecedent cognitive reappraisals Handling threat perceptions Modifying negative attributional biases Preventing emotional avoidance Focusing on helping patients focus on uncomfortable emotions without avoidance Modifying action tendencies Encountering avoided behaviors, increasing approach Decreased distraction rumination, inhibition

Summary Transdiagnostic approaches serve Parsimony Training More ecological valid patient care

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