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Contents lists available at ScienceDirect

Journal of Anxiety Disorders

The new transdiagnostic cognitive behavioral treatments:

Commentary for clinicians and clinical researchers
Peter C. Meidlinger, Debra A. Hope ∗
University of Nebraska-Lincoln, United States

a r t i c l e i n f o a b s t r a c t

Article history: Recognition of the limitations of the current categorical diagnostic system and increased understanding of
Received 6 July 2016 commonalities across clinical problems associated with negative emotion, including anxiety and depres-
Received in revised form 27 October 2016 sion, has led to the development of transdiagnostic psychological interventions. This new approach holds
Accepted 4 November 2016
promise in shifting our emphasis from diagnostic categories to treating core construct that cut across dis-
Available online xxx
orders. This paper identifies some of the similarities and differences across various cognitive-behavioral
transdiagnostic protocols and key challenges in assessment and case conceptualization for clinicians
Keywords:
wishing to use this approach. Some key needs in the research literature that would be particularly helpful
Transdiagnostic treatment
Cognitive behavioral therapy
to clinicians are also identified.
Treatment recommendations
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
As the first author embarked on graduate school, his father, a
practicing psychologist with more than 30 years of clinical experi-
ence, told him that the classification of mental health problems in
the dominant paradigm, then the Diagnostic and Statistical Manual
of Mental Disorders, IV-TR (APA, 2000), was at the place where classi-
fication of species was prior to Linnaeus, when people categorized
creatures into “animals with tails and animals without” (J. Mei-
dlinger, personal communication, March 22, 2011). While there is
a certain degree of hyperbole in the statement, one does not need to
engage in clinical practice or conduct research for very long before
the limitations of our diagnostic system becoming apparent.
A number of theorists and researchers have identified problems
in the current categorical diagnostic system (e.g., Brown et al., 1998;
Watson, 2005; Widiger & Samuel, 2005). Three common critiques
are (a) high comorbidity, (b) loss of important information that does
not fit a category, and (c) lack of support for distinctiveness of the
categories. There is substantial comorbidity across psychiatric dis-
orders, with nearly half of all individuals with one disorder also
meeting criteria for a second (Kessler et al., 2005). Additionally,
these diagnoses have significant overlap in symptoms and criteria,
a factor that is indicative of the lack of true categorical boundaries.
While these overlapping symptoms can be seen as the reason for
the high comorbidity, it has been argued that both the symptom
∗ Corresponding author.
E-mail address: dhope1@unl.edu (D.A. Hope).
overlap and the comorbidity are actually the product of shared
underlying processes, which produce varying symptom manifes-
tations (e.g., Krueger & Markon, 2006).
Secondly, in categorical classification systems such as the DSM,
information that is clinically relevant may also be lost or ignored if it
fails to meet criteria for a specific diagnosis (e.g., Widiger & Samuel,
2005). This issue is pervasive in clinical practice where it is not
unusual to see individuals with subclinical but relevant diagnoses
such as an individual with social anxiety disorder that has panic-
like reactions to interoceptive stimuli or an individual diagnosed
with generalized anxiety disorder who has some intrusive thoughts
and safety behaviors that resemble obsessive-compulsive disorder.
Finally, analyses of the structure of the current diagnostic
scheme typically indicate greater commonality across anxiety-
related and unipolar depressive disorders than should be the case
for exclusive categories (e.g., Brown et al., 1998; Brown, 2007).
These models tend to indicate two higher order factors labeled
positive and negative affect. While this does not negate the util-
ity of the diagnostic scheme, it does indicate that the categories
may be constructs of convenience rather than objective categories.
This is further bolstered by evidence indicating shared risk factors
(e.g., Hettema, Neale, Myers, Prescott, & Kendler, 2005; Kendler
et al., 2011; Kendler, Prescott, Myers, & Neale, 2003) and maintain-
ing processes (e.g., Clark, 1999; Hayes, Wilson, Gifford, Follette, &
Strosahl, 1996) broadly across diagnostic categories.
This focus on artificially bounded diagnoses has resulted in a
tendency for research programs to be siloed around them, hinder-
ing generalization of research findings across disorders that may
share common mechanisms. Social anxiety disorder, for instance,

http://dx.doi.org/10.1016/j.janxdis.2016.11.002
0887-6185/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
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was once termed the “forgotten anxiety disorder” (Turner & Beidel,
1989) because intervention research lagged behind other anxiety-
related diagnoses in spite of the fact that similar exposure-based
treatment is broadly effective for it (e.g., Acarturk, Cuijpers, van
Straten, & de Graaf, 2009). Transdiagnostic treatments offer a
potent means of addressing many of these criticisms while also
offering treatments that may be more easily disseminated. These
treatments approach psychopathology through constructs shared
across diagnosis, using common treatment components to address
them. As will be seen below, the nature and approach of these
treatments varies however.
2. What are transdiagnostic treatments
2.1. Transdiagnostic language
One issue when examining the literature on transdiagnostic
treatments is that researchers lack a shared language to discuss
these treatments and the terms used are often inexact. We bring
this up in order to be open about the limitations of the language we
use and define them as much as we are able. Both the umbrella term
“transdiagnostic” and the treatment targets themselves are key
examples of this issue. The term transdiagnostic implies a reliance
on the present diagnostic system, which, as detailed above, may
lack validity and utility. While the published treatment protocols
encourage diagnostic assessment in order to obtain information in
sufficient breadth, some encourage a treatment approach that may
be equally well-defined as adiagnostic. We use the term transdiag-
nostic with these limitations in mind.
The terms for treatment targets are similarly fraught with dif-
ficulty. Some transdiagnostic treatments (e.g., Norton 2012) target
“anxiety disorders” but changes in DSM-5 to remove some disor-
ders from this grouping limit the utility of this label (APA, 2013).
Developers of these treatments are now stuck with defining treat-
ments targets as anxiety disorders, obsessive-compulsive disorder,
posttraumatic stress disorder, and illness anxiety disorder. Sim-
ilarly, in defining the scope of the Unified Protocol (UP; Barlow
et al., 2010) the authors argue that DSM-IV-TR anxiety disor-
ders and unipolar depression fall under the higher order category
of “emotional disorders” with subsequent publications arguing
that borderline personality disorder also falls under this umbrella
(Sauer-Zavala & Barlow, 2014; Sauer-Zavala, Bentley, & Wilner,
2016). Certain technical boundaries are placed on this definition by
the authors but any such boundaries are difficult to define (should
intermittent explosive disorder be an emotional disorder?). The
complexity of these applications is emblematic of the deficits in
present diagnostic system and also the difficulty of retrofitting a
transdiagnostic dimensional system to a categorical system. This
problem will likely be resolved as research on psychopathology
continues to move beyond DSM categories and can further inform
appropriate treatment targets.
2.2. Transdiagnostic treatments
A number of prominent transdiagnostic treatments have arisen
in the past decade, most prominently the UP (Barlow et al., 2010)
and Transdiagnostic Cognitive Behavioral Group Therapy (TGCBT;
Norton, 2012). These treatments have largely shown themselves to
be effective relative to waitlist controls (e.g., Farchione et al., 2012;
Norton & Hope, 2005), other transdiagnostic treatments (e.g., relax-
ation; Norton, 2011), and some preliminary evidence indicates they
are as effective as diagnosis-specific treatment (Norton & Barrera,
2012). While past discussion of divisions of these treatments have
focused on treatment origins, dividing them into theory- and
pragmatically-derived treatments (Clark & Taylor, 2009), from a
Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
practical perspective that may be especially relevant to clinicians,
the treatments can be divided into two groups based on imple-
mentation. The division then is between integrative treatments
that focus on the implementation of a single unified process across
pathology (e.g., Gros, 2014; Norton, 2012; Schmidt et al., 2012) and
modular, mechanism- focused treatments that use a discrete set
of treatment mechanisms that are implemented across disorders
(e.g., Barlow et al., 2010).
While there are a number of different transdiagnostic treat-
ments they are, at their core, quite similar. For all of these
treatments (e.g., Barlow et al., 2010; Gros, 2014; Norton 2012;
Schmidt et al., 2012) it is arguable that the core active treatment
component is decreasing behavioral and experiential avoidance
(e.g., Gros, 2014; Norton, 2012) or what the UP refers to as emotion-
driven behaviors (Ellard, Fairholme, Boisseau, Farchione, & Barlow,
2010). In fact, this core piece is consistent not only across trans-
diagnostic treatments but also across disorder- specific cognitive
behavioral treatments (CBT; e.g., Barlow and Craske, 2007; Hope,
Heimberg, & Turk, 2010) and acceptance and commitment thera-
pies (e.g., Hayes-Skelton, Orsillo, & Roemer, 2013). As with many
disorder-specific CBT interventions, many of the transdiagnostic
treatments also include one or more emotion-regulation strategies,
such as cognitive restructuring (e.g., Norton, 2012) and/or mind-
fulness (e.g., Barlow et al., 2010) for example. Such commonalities
across approaches may help facilitate training in transdiagnostic
approaches if clinicians have disorder-specific treatment experi-
ence.
Although the core of these treatments is similar, the implemen-
tation of that core differs substantially in ways that may be clinically
meaningful for clients. The integrative treatments typically focus
on a single set of procedures that are repeatedly implemented
across various situations or experiences that are relevant to the
client. Norton (2012) combines exposure with cognitive restructur-
ing. Other protocols focus more exclusively on reducing avoidance
(Gros, 2014; Schmidt et al., 2012). This singular structure offers
some advantages. The model for treatment is notably simpler,
which may make it easier for clinicians and clients to understand
and internalize. This simplicity may be increasingly important to
consider when working with clients with cognitive deficits that
may impact learning, memory, and application of skills (e.g., atten-
tional problems, memory deficits, low IQ).
Alternatively, the mechanistic/modular treatments such as the
UP offer a broader array treatment tools (e.g., cognitive restructur-
ing and mindfulness; Barlow et al., 2010). While this may be more
complicated for clients to internalize and apply, it also offers dif-
ferent means of approaching behavioral change and may address a
broader range of underlying constructs. This may offer some ben-
efit when clients are struggling to make progress as it allows the
therapist to shift approaches to emphasize what is effective for each
client.
2.3. Assessment
The advent of transdiagnostic treatments requires parallel inno-
vation in assessment of psychopathology and clinical outcomes.
This includes some substantive theoretical work examining the
underpinnings of transdiagnostic treatments and some general
recommendations across the various treatment modalities for
approaching both initial assessment and treatment monitoring.
Four relevant frameworks are described below–focusing varyingly
on symptoms, treatment targets, underlying processes, and under-
lying constructs.
Brown and Barlow (2009) proposed a symptom-focused dimen-
sional classification system for mood and anxiety disorders
based on a number of empirically supported constructs. These
dimensions include: anxiety/neuroticism/behavioral inhibition;
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behavioral activation/positive affect; unipolar depression; mania;
somatic anxiety; panic and related autonomic surges; intrusive
cognitions; social evaluations; past trauma; behavioral and inte-
roceptive avoidance; and cognitive and emotional avoidance. An
assessment tool based on existing measures is being developed
(Rosellini & Brown, 2014). While both the model and the assess-
ment approach are promising in terms of their ability to offer a
more nuanced and useful examination of clients’ presenting prob-
lems, this model and assessment approach are still largely based
on adding a dimensional scheme to existing categorical diagnoses.
This symptom focus may miss underlying processes or constructs
that are relevant to the symptom profiles.
A similar, but much simpler treatment-focused heuristic, was
developed by Gros (2014) as the basis for his transdiagnostic
behavior therapy protocol. In this protocol negative emotions are
conceptualized as being the product of four types of avoidance:
situations, interoceptive cues, thoughts, or positive emotions and
treatment follows an individualized plan of exposures to these
avoidance areas. While this treatment protocol is still in the early
stages of gaining empirical support, this heuristic of categories of
avoidance is a useful one to consider when assessing and determin-
ing treatment across many transdiagnostic protocols.
Other researchers have proposed moving to a more process
driven approach (e.g., Harvey, Watkins, Mansell, & Shafran, 2004;
Mansell, Harvey, Watkins, & Shafran, 2009). They argue that diag-
nosis is unnecessary for transdiagnostic treatment and, as such,
assessment should focus on underlying processes rather than diag-
nosis. The authors identify 12 possible transdiagnostic processes
(e.g., interpretational bias, explicit selective memory) across 5
domains (i.e., attention, memory, reasoning, thought, and behav-
ior). Such models are still relatively early in their development but
may prove useful in guiding treatment in the future.
Another interesting developing area has been in the exami-
nation of transdiagnostic constructs that may underlie pathology
across disorders. Several, among many, promising ones include
anxiety sensitivity (e.g., Boswell et al., 2013; Carleton, Sharpe, &
Asmundson, 2007), distress tolerance (e.g., Wolitzky-Taylor et al.,
2015; Zvolensky, Vujanovic, Bernstein, & Leyro, 2010), rumination
(e.g., Hsu et al., 2015; Spinhoven, Drost, van Hemert, & Penninx,
2015) and intolerance of uncertainty (e.g., Carleton et al., 2007;
McEvoy & Mahoney, 2012). Recent work on modeling the rela-
tionship between these factors and disorders has indicated that
both anxiety sensitivity and intolerance of uncertainty contributed
significant information to hierarchical models including negative
affect (Norton & Mehta, 2007; Paulus, Talkovsky et al., 2015). These
construct- focused models offer some promise towards providing
finer-grained understanding as well as providing clinically useful
information as constructs may be linked to treatment approaches
(e.g., anxiety sensitivity responding to interoceptive exposure).
While it is too early in the research to guess how all (or none)
of these frameworks will inform our future changes in our under-
standing of diagnosis, it is our opinion that all of these approaches
offer substantial strengths. Rather than reflecting conflicting view-
points, the differences in these reflect different levels of analysis.
As such, we feel all of these may be useful when assessing and
conceptualizing cases transdiagnostically.
2.4. Intake assessment
Both the UP (Barlow et al., 2010, p. 5–6) and Norton (2012,
p. 47) recommend that treatment begin with a standard biopsy-
chosocial assessment including some form of diagnostic interview,
whether unstructured or structured. These structured interviews
include a variety of assessments such as the Anxiety Disorders
Interview Schedule for the DSM-5 (Brown & Barlow, 2014), the
Structured Clinical Interview for the DSM-5 (First, Williams, Karg,
Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
3
& Spitzer, 2016), or the Mini International Neuropsychiatric Inter-
view (Sheehan et al., 1997). These structured assessments offer
opportunity to assess both the presenting problem, broader stress-
ors, and, importantly, subclinical problems that may be beneficial
if addressed in treatment. Of these instruments it is notable that
the ADIS-5 is the only one that offers dimensional rating scales,
which may be of particular use for including subclinical diagnoses
when preparing for transdiagnostic treatment. Regardless of the
instrument chosen, it is important to continue to maintain a trans-
diagnostic perspective while conducting diagnostic assessment.
Pursuant to this, we would offer two recommendations attached
to the use of these instruments. The first of these is that, regardless
of whether the instrument examines disorders dimensionally, the
assessor approaches them in this manner, noting significant sub-
clinical symptoms. While there are no formal assessments designed
to accomplish this, keeping a conceptual framework in mind such as
Brown and Barlow’s (2009) or Gros’ (2014) during assessment can
help guide practical, treatment-focused questions. In our opinion,
there is a great deal of clinical utility in knowing subclinical diag-
noses of clients (e.g., if a client with PTSD has panic-like symptoms).
This is particularly true in a transdiagnostic treatment, where a
major strength is that subclinical but impairing diagnoses can be
readily included in treatment.
The second recommendation we would make is to view the DSM
categories based more on their functional analytic core. This is a
practice that many cognitive-behavioral clinicians and researchers
do implicitly but it is useful to define explicitly as well. The DSM
criteria for panic disorder are an excellent example of this. The cri-
teria in the DSM contain no reference to interoceptive sensitivity,
however a great deal of research supports this being the core fear
of panic disorder (e.g., McNally, 2002; Taylor, Koch, & McNally,
1992). Because of this, clinicians and researchers often concep-
tualize the disorder as a disorder of interoceptive sensitivity and
associated escape/avoidance responses and, in assessing panic dis-
order, often explicitly elicit information regarding these constructs
from clients. Because the transdiagnostic treatments free clinicians
from the need to have diagnosis define treatment in the way that
it did for disorder-specific treatments, the functional analytic per-
spective has more utility and should be pursued.
3. Idiographic case formulation
3.1. Diagnostically driven case formulation
Traditionally case conceptualization has stemmed from gener-
ally accepted models of disorder-specific pathology. In this vein,
the conceptualization for an individual with social anxiety disor-
der may be built using the cognitive behavioral model proposed
by Rapee and Heimberg (1997) and inserting idiographic informa-
tion as applicable into the component pieces. While this is tenable
for individuals with only a single disorder, when there are multi-
ple diagnoses it becomes increasingly difficult to merge multiple
models into a single useful whole. Furthermore, individuals with
multiple diagnoses may be substantially different than individu-
als with one of their constituent diagnoses (Norton & Chase, 2015).
Thus, ideographic case formulation that integrates all presenting
problems may be more appropriate.
3.2. Idiographic transdiagnostic case formulation
Idiographic case formulation involves the development of a
hypothesized mechanism that underlies the presenting problem(s)
(e.g., Haynes, O’Brien, & Kaholokula, 2011; Kuyken, Padesky, &
Dudley, 2009; Persons, 2008). A case can be formulated at mul-
tiple levels. For example, an overall case formulation will include
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all of the presenting clinical issues as well as overall background of
the client. Cases can also be formulated around a particular prob-
lem such as procrastination or inability to maintain employment
or a particular situation such as an argument with family member
last weekend. Case formulation is most useful when the hypoth-
esized mechanism can be evaluated empirically and it leads to a
plan for intervention. In an evidence-based context, case formu-
lation includes consideration of research on psychopathology for
given diagnoses or presenting problems. For example, a formula-
tion for panic attacks will include interceptive conditioning and
catastrophic misinterpretation of physical sensations while rec-
ognizing ideographic considerations−“I fear I am having a heart
attack. My father died of a heart attack at about my age.”
Ideographic case formulation, especially as described by Persons
(2008) fits well in a transdiagnostic context because it involves
integrating information across all diagnoses to have a global
understanding of the context and presenting problem(s). Thus,
the clinician may consider the following problem list–depressed
mood, underemployed, few friends, relationship problems, social
anxiety—and determine that avoidance of challenging situations
(new people/situations, conflict) is a common mechanism, per-
haps driven by dysfunctional cognition or lack of reinforcement
due to poor social skills. (The cognition vs. social skills deficit could
be distinguished with further assessment.) Avoidance behavior,
dysfunctional cognition, and poor social skills are all evidence-
based mechanisms (e.g., Heimberg et al., 1998; Herbert et al., 2005;
Mattick, Peters, & Clarke, 1989) for the various presenting problems
though that research has often been tied to particular diagnoses.
The particular disorders that present are less relevant here as the
clinician looks for interventions that target these mechanisms. The
advantage of transdiagnostic treatment packages is that the clini-
cian need not cobble together interventions from several protocols.
Rather there is an integrated treatment already available.
If all clients receive all of the interventions in a transdiagnostic
treatment, then one could argue that ideographic case formulation
is not necessary. However, we propose that it is especially useful in
this context for two reasons. First, all of the current transdiagnos-
tic interventions allow for flexibility to tailor the treatment to the
individual client. Case formulation can help guide those decisions.
Second, the formulation can help the client understand how vari-
ous problems might be related and increase motivation to engage
in treatment that will be more broadly helpful than it might appear
on the surface.
3.3. Treatment monitoring
Across CBT treatment protocols there has been a consistent
emphasis on ongoing and continuous assessment. This ongo-
ing assessment serves a variety of purposes, including tracking
progress and determining when to terminate treatment, provid-
ing clients some objective feedback on progress, and assisting in
the hypothesis testing that is at the core of scientist-practitioner
model. Tracking progress and outcome in treatment using disorder-
specific measures (e.g., Social Phobia Scale (Heimberg, Mueller,
Holt, Hope, & Liebowitz, 1992)) creates methodological problems in
both transdiagnostic research (Gros, 2014) and in clinical practice.
For example, a given measure may not be equally relevant across
all participants. Clinicians have more flexibility to choose the most
relevant measure but, as discussed below, the assessment burden is
high if multiple measures as needed. Two approaches to assessment
will be described below, both of which use standardized measures.
3.4. Traditional measures of psychopathology
While not ideal in a treatment study, disorder-specific mea-
sures are still a viable option in individual or group treatment in
Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
clinical settings. However it requires specific tailoring to match
the client’s symptom profile. This can be done simply either by
selecting measures that match the diagnoses of the client or by
selecting measures that match the hypothesized constructs under-
lying the client’s diagnostic profile. These two approaches may
often yield the same results but a focus on underlying constructs
may prove more parsimonious in a diagnostically complex case. A
client meeting criteria for generalized anxiety disorder, obsessive-
compulsive disorder, and panic disorder may receive three mea-
sures using diagnosis as a guide, while a conceptualization-based
monitoring plan may conclude that a construct such as intolerance
of uncertainty underlies the client’s pathology and is sufficient for
monitoring.
This approach is somewhat cumbersome in terms of the require-
ments on the clinician and may be burdensome on the client. Also,
in some settings it is helpful to have a uniform measure across
clients to allow aggregation of data for program evaluation. The
alternative is to default to well-validated but broader measures
of distress. In this role, treatment studies tend to have used the
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996),
the Beck Anxiety Inventory (BAI; Beck & Steer, 1990), the Depres-
sion Anxiety and Stress Scales-21 item version (DASS-21; Henry
& Crawford, 2005), or the State Trait Anxiety Inventory (STAI;
Spielberger, 1983). While it is beyond the scope of this paper to
review the merits of these measures in depth, they all have their
own strengths and are fully appropriate for a wide variety of clients.
The broadest and most inclusive of these measures is the DASS-
21, the only one of the measures above that provides indices of
both depression and anxiety. As such, it may be the simplest of
the existing measures in cases where there is a need to standard-
ize measurement across clients. For this reason we have used a
modified version of the DASS-21 that includes two items assess-
ing suicidal ideation in our clinic. Of course, there are other more
general measures such as the Kessler 10 (K-10; Kessler et al., 2002)
or the Hospital Anxiety and Depression Scale (HADS; Zigmond &
Snaith, 1983) which could be appropriate for assessing progress
with transdiagnostic treatments but these have tended not to be
used in the studies evaluating the treatments to date.
3.5. Measures of functioning
To a certain extent the evaluation of treatment outcome is con-
tingent on changes in a client’s daily functioning. Assessments of
functioning have seen significant use in research examining phys-
ical health problems (e.g., Von Korff et al., 2005; Yellen, Cella,
Webster, Blendowski, & Kaplan, 1997) and research on severe men-
tal illness (e.g., Harding, Brooks, Ashikaga, Strauss, & Breier, 1987;
Saavedra, Lopez, Gonzalez, Arias, & Crawford, 2015). Functional
measures are appealing because they rely heavily on behavioral
indicators, which are often more reliable indicators of change.
Unfortunately, many of these measures are focused on medical
impairment and have significant ceilings when applied to individu-
als with anxiety and depression typically seen in outpatient setting.
The World Health Organization Disability Assessment Schedule
(WHODAS 2.0; Ustun, Kostanjsek, Chatterji, & Rehm, 2010), for
instance, assesses a number of abilities that one would expect either
to not be impaired in almost all mental health clients (e.g., “Stand-
ing up from sitting down”) or impaired in only a select group of
mental health clients (e.g., “Eating”).
There are at least two measures of functioning that have seen use
in transdiagnostic treatment studies including the clinician-rated
Work and Social Adjustment Scale (WSAS; Mundt, Marks, Shear, &
Greist, 2002) and the self-report Illness Intrusiveness Rating Scale
(IIRS; Devins et al., 1983). These measures provide useful infor-
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mation relevant to the evaluation of treatments and can usefully
supplement more subjective measures.
3.6. Assessment recommendations
While there are a large number of potential options for initial
and ongoing assessment it is difficult to establish clear rules in the
absence of any established research in the area. With that caveat in
mind, our general clinical approach has been as follows. We typi-
cally recommend using some form of structured interview, simply
because it offers the broadest picture of the clinical problems a
client may have. We always then recommend building an idio-
graphic case conceptualization around this information, including
both information from diagnoses that meet diagnostic threshold
(e.g., for an individual with social anxiety this may include infor-
mation such as marked anxiety in situations, avoidance of group
social contact, diminished enjoyment of social interaction etc.) and
information from subthreshold problems (e.g., anxiety regarding
the safety of loved ones) to build a model of treatment targets. This
idiographic model should be informed by more nomothetic models
of psychopathology (e.g., Rapee & Heimberg, 1997) as is applicable
to the individual case. We recommend that the ongoing assess-
ment focus on a parsimonious attempt to capture this idiographic
model. For many cases this may be no different than is current typi-
cal practice, using standardized symptom-focused measures. While
not typically used in treatment research, we would argue that some
of the process-focused measures discussed above (e.g., rumination,
anxiety sensitivity, distress tolerance) may better capture links
across multiple diagnoses for some individuals. For instance, an
individual with panic disorder, illness anxiety disorder, and post-
traumatic stress disorder may be best monitored using a measure
of anxiety sensitivity given the role that interoceptive sensitiv-
ity plays in all these disorders (e.g., McNally, 2002; Taylor, 2003).
Similarly, a measure of rumination may be a good choice for an indi-
vidual who presents with ruminative depression and social anxiety
characterized by post- interaction rumination.
4. Considerations for treatment format
4.1. Individual and group formats
For most psychological treatments, the default format of treat-
ment administration has been weekly individual therapy sessions
or weekly group therapy sessions. While many transdiagnostic
treatments have been only formally evaluated in randomized con-
trolled trials in either group (e.g., Gros, 2014; Norton & Hope, 2005)
or individual (Farchione et al., 2012; Schmidt et al., 2012) format,
there are some indications that both the UP (Bullis et al., 2015)
and TGCBT (Paulus & Norton, 2016) can and have been success-
fully administered in the alternate format. In our opinion, there
are no clear reasons to expect that these treatments could not be
translated across treatment formats and remain efficacious.
There are, however, considerations when selecting treatment
format for clients. Individual format may be more appropriate
for clients with complexity that may be difficult to address in
a group context or who may be disruptive to group process,
although Norton (2012, p. 36) argues that disruptive clients tend
to self-correct. Additionally, Norton recommends that clients for
whom the nature of their anxiety is particularly difficult to dis-
close or address in front of others (e.g., sexual obsessions, sexual
trauma) should be placed in individual treatment. Beyond this,
however, Norton offers few limitations on inclusion in transdiag-
nostic groups.
Research indicates that diagnostic heterogeneity in transdiag-
nostic groups does not impact outcome (Chamberlain & Norton,
Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
5
2013). Anecdotally, clients in transdiagnostic groups tend to recog-
nize more similarities in their problems than do clinicians trained
in diagnosis-driven treatment. There is some evidence that eth-
nic/racial differences may have some impact on group cohesion
and outcome. Paulus, Hayes-Skelton, Norton (2015) found that very
diverse groups, in which no two individuals shared a racial/ethnic
identity, group outcomes were lower. These findings were not
present for any other segment of their sample, including diverse
groups where any two or more individuals shared an ethnic or
racial identity. Following their recommendations, in groups where
no individuals share an ethnic/racial identity, multicultural issues
should be addressed more directly and openly throughout the
group.
4.2. Transdiagnostic or diagnosis specific treatment
At present, there is little empirical data to guide a clinician or
client in choosing between transdiagnostic versus disorder-specific
approaches. While this is an important research question, it is also
important practically to consider the availability of specific treat-
ments. Dissemination has historically been one of the most difficult
part of implementing empirically supported treatments (Barlow,
Levitt, & Bufka, 1999; McHugh & Barlow, 2010). One of the major
benefits of transdiagnostic treatments may be that they simplify
dissemination by requiring training on fewer protocols (McHugh,
Murray, & Barlow, 2009).
As discussed above, the validity of the DSM diagnostic system
has been seriously challenged but this is not to say that disorder-
specific treatments are not effective. A large body of treatment
outcome literature shows that they most certainly are helpful for
many people (e.g., Barlow, Craske, Cerny, & Klosko, 1989; Jacobson,
Martell, & Dmidjian, 2001; Ledley et al., 2009). It may be that the
mechanisms of action are through constructs related to but not
distinct from a particular disorder (e.g., anxiety sensitivity in panic
disorder (McNally, 2002)) but it may be close enough that it is effec-
tive for a majority of clients meeting criteria for the disorder. One
important challenge for researchers is to determine whether cer-
tain cases are better treated with a disorder specific treatment both
clarifying treatment as applied to the current diagnostic scheme as
well as identifying underlying constructs.
Schmidt et al. (2012) argue that the utility of transdiagnostic
treatments is, “. . .likely to be where these treatments offer clear
advantages over existing CBT protocols.” Where this advantage lies
is likely to be in treating individuals who have multiple disorders
that provide substantial impairment, individuals who fit poorly
in to present diagnostic categories, or individuals whose primary
diagnosis is exacerbated by or interlinked with a secondary diag-
nosis (e.g., an individual with primary social anxiety disorder and
panic disorder who has panic attacks in social contexts). Disorder-
specific treatments may have an advantage in treating individuals
with only a single diagnosis or individuals with a primary diag-
nosis that should be the principle focus of treatment. Newby,
Mewton, & Andrews (this issue) found some early but tantaliz-
ing results in their study comparing transdiagnostic internet-based
CBT to disorder specific internet-based CBT for comorbid depres-
sion and generalized anxiety disorder. This study suggested small
differences in favor of transdiagnostic treatment for the comorbid
condition. While this is a single study focused on two diagnoses, it
provides some early evidence that transdiagnostic treatments may
be more effective in treating comorbid diagnoses. More research is
needed to determine when and if a transdiagnostic approach leads
to superior clinical outcomes.
In terms of sequencing disorder-specific and transdiagnostic
treatments there is no clear empirical guidance for possible treat-
ment outcomes or how to order treatments. In general, all of these
CBT treatments, both disorder-specific and transdiagnostic, are
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6 P.C. Meidlinger, D.A. Hope / Journal of Anxiety Disorders xxx (2016) xxx–xxx
based mostly on principles of behavioral activation and/or expo-
sure. As such, they are often conceptually compatible with one
another and, in clinical work, one would expect little difficulty
shifting between them if the client finds the treatment rationale
to be credible. If the client is a treatment non-responder, we think
shifting to a conceptually similar treatment may be most benefi-
cial if there is a clear rationale for the shift (e.g., the client needs to
address anxiety across a number of diagnoses) based on research
into the importance of treatment credibility (e.g., Safren, Heimberg,
& Juster, 1997). In other cases where the client is a non-responder
for unclear reasons, we feel it may be most beneficial to shift to an
approach with a more dissimilar rationale such as acceptance and
commitment therapy, as a similar treatment may lack credibility
for that particular client. Research that addressed the sequencing
of transdiagnostic and disorder-specific treatments across modali-
ties as part of an overall evaluation of stepped care models (Bower
& Gilbody, 2005) would be very useful.
5. Training considerations in transdiagnostic treatments
Training clinicians to effectively conduct transdiagnostic treat-
ments may be influenced by a number of factors including therapist
experiences and familiarity with CBT interventions in general.
However, the limited research on training has not identified bar-
riers to treatment. Gros, Szafranski, and Shead (2016) found that
a four-hour seminar given to experienced clinicians was sufficient
for them to be able to implement the treatment effectively. How-
ever, the prior training in and experience with similar exposure-
and behavioral activation-based interventions was not assessed,
a factor that may have facilitated learning. Norton, Little, and
Wetterneck (2014) indicated that therapist experience did not pre-
dict outcome in implementation of TGCBT, however all therapists
were supervised by an expert in the treatment, which may have
mitigated any experience gap.
When training graduate students or clinicians with little CBT
experience, one would expect the learning curve to be a little bit
shallower and require ongoing supervision to aid in treatment
implementation. Given the diversity of clients seen in transdiag-
nostic protocols, perhaps training should be extended until the
therapist has seen a variety of cases. For example, Gros’ (2014) four
types of avoidance and exposure (or three if the treatment does not
include depression) may again be a useful heuristic for determining
the set of experiences a therapist needs before being fully trained
in the treatment.
One factor we have observed in our experience in training on
Norton’s TGCBT is the difficulty that therapists have in shifting
to a transdiagnostic conceptualization of cases. Therapists who
have worked within a DSM system often struggle to implement
treatment plans that cross cut diagnostic lines rather than treat-
ing co-morbid diagnoses sequentially. For example, for a client
who meets criteria for both social anxiety disorder and obsessive-
compulsive disorder, a therapist inexperienced in transdiagnostic
approaches may tend to treat one disorder then the other rather
than focus on a common construct such as “situations in which you
cannot control the outcome.” In contrast, clients in transdiagnostic
groups see many commonalities with each other, irrespective of
diagnosis.
6. Research directions
While research into transdiagnostic treatments has made great
strides in recent years, the field is still relatively new with impor-
tant research domains that are still largely open for investigation.
One of the most salient of these is basic research into the nature
and structure of psychopathology. Although research has indicated
Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
that the present diagnostic system lacks validity, no established
alternative has emerged from the competing models. Approaches
focused on underlying process and constructs of psychopathology
(e.g., Mansell et al., 2009; Paulus, Talkovsky et al., 2015) that lead
to identification of maintenance processes and transdiagnostic con-
structs, rather than symptoms, seem most promising.
While it is beyond the scope of this paper to discuss them at
length, there are a number of constructs that appear to be func-
tionally important across disorders. These include constructs such
as distress tolerance, intolerance of uncertainty, rumination, anx-
iety sensitivity, experiential avoidance, among many. While the
research on many of these provides a sense of the breadth and depth
of their importance, we know very little about how most of these
cross-cutting constructs may relate to each other, how they may
produce different clinical presentations, and how that may impact
treatment.
Associated with new models is the need to build evidence-based
clinical assessment tools. As stated before, we posit that many
clinicians presently use the diagnostic interview to elicit informa-
tion about the constructs underlying diagnoses (e.g., intolerance
of uncertainty, fear of negative evaluation) but movement should
be made towards building standardized instruments for assessing
these underlying factors explicitly, potentially based on the mod-
els gleaned from the more basic research into psychopathology
detailed above. Ultimately, however, we recognize that much of
the assessment that drives treatment is based more on functional
analysis than it is on symptom or construct measures, which does
not lend itself to standardization. So, while we would recommend
that research move towards a new and deeper understanding of
psychopathology, we would also recommend expanded training
in functional analysis in graduate training for all mental health
professionals.
The lack of assessment tools creates difficulty in research as well.
It remains unclear what outcome measures should be in studies of
transdiagnostic treatments. The current symptom/disorder specific
measures are inadequate. Decades of psychotherapy research has
focused on decreasing negative emotions with insufficient atten-
tion to assessing positive emotions. For both transdiagnostic and
disorder-specific treatments we need to measure both negative
and positive emotionality and functional impairment and quality
of life as well as move towards assessing outcome using important
latent constructs (e.g., anxiety sensitivity, intolerance of uncer-
tainty) across mental health problems.
While the proposed research into new ways modeling the
structure of psychopathology will likely lead to equally signifi-
cant changes in transdiagnostic treatments, there are presently a
number of important empirical questions to be answered about
transdiagnostic treatments themselves. We do not yet have an
understanding of the long term outcomes of transdiagnostic treat-
ments or a fully developed sense of the differential impact of
transdiagnostic CBT and disorder-specific CBT on both primary and
secondary symptoms. Even the idea that they may be more easily
disseminated and implemented has only limited research support.
While we expect that transdiagnostic treatments may gradu-
ally supplant many disorder-specific treatments, if for no reason
other than ease of dissemination, we would caution researchers
not to ignore disorder-specific treatments. While targeting diag-
nostic categories with limited validity creates a great deal of noise
in the system, it should be recognized that there is also signal there.
It is not difficult to imagine some shifting of treatment components
from diagnostic targets (e.g., social anxiety disorder) to construct-
based targets (e.g., overestimation of the cost of social failure) will
occur as supporting evidence develops about what key constructs
addressed in those treatments. Research examining the utility of
adding optional diagnosis-specific (or, more appropriately, con-
struct specific) modules for transdiagnostic treatments may prove
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ANXDIS-1898; No. of Pages 9 ARTICLE IN PRESS
P.C. Meidlinger, D.A. Hope / Journal of Anxiety Disorders xxx (2016) xxx–xxx
useful, perhaps something similar to Chorpita and Weisz (2009)
approach to treating children.
7. Conclusions
Transdiagnostic treatments offer a number of appealing advan-
tages to the mental health field. These include conceptual
advantages such as better matching research-driven models of
mental health problems, health care system advantages such as
improved ease of dissemination, and basic clinical advantages such
as improvements in the ability to address comorbidity.
While it has been argued that transdiagnostic treatments repre-
sent a niche treatment (Clark, 2009), the above factors indicate that
transdiagnostic approaches represent the beginning of a paradigm
shift in how we conceptualize and treat psychopathology.
With that said, these treatments still rely on the fundamental
principles that behavioral treatments have used for decades. The
core of all of these treatments is some combination of exposure and
behavioral activation guided by functional analysis, often combined
with an emotion-regulation strategy. They all have different com-
ponents attached to this core and different ways of approaching
this but they share significant commonalities. It has been argued,
in fact, that this movement is a return to the past when behavior
therapy did not use diagnosis to direct treatment (e.g., McManus,
Shafran, & Cooper, 2010). This bears mentioning as many of these
transdiagnostic treatments may resemble approaches that some
behaviorally-trained clinicians already use in their work. As such,
the transdiagnostic approach may be offering very little that is
really new, especially when considering a history that predates
DSM.
That said, these treatments approach psychopathology from a
fundamentally different perspective than we have done as a field
in recent decades. Implementing them effectively requires a sig-
nificant effort on the part of the clinician to alter their clinical
perspective and treatment approach from using a diagnosis-
specific mechanism to reduce diagnosis-related symptoms to one
centered around utilizing a broad process to improve an individ-
ual’s quality of life.
As a specific example of the shift in thinking, we can think of
one case we would previously have treated as “a panicker” but that,
using Norton’s (2012) treatment, we approached as an individual
with a high need for control and heightened anxiety sensitivity,
which resulted in both panic attacks and rigidity in other facets
of the individual’s life. Exposures involved interoceptive exercises
and cognitive restructuring centered on his belief that the individ-
ual needed to control symptoms of anxiety and exposures centered
around other areas where his desire for control resulted in dis-
tress and impairment but were not associated with any diagnosis
(e.g., excessive speeding and anger about being late). One of the
great unsung advantages of transdiagnostic treatments is not just
that they treat comorbid diagnoses better but that they encourage
treatment of underlying tendencies more broadly and potentially
foster greater generalization of the skills learned.
While there is great promise in transdiagnostic treatments and
great utility for clinicians, there are, as of yet, relatively few treat-
ment studies and there are still substantial gaps in the broader
research base underlying these treatments. It is also entirely pos-
sible that greater understanding of the cross-cutting constructs
underlying psychopathology may yet point an entirely different
direction for the best intervention. However, right now transdi-
agnostic approaches offer much to pique the curiosity of clinicians
and researchers alike.
Please cite this article in press as: Meidlinger, P. C., & Hope, D.A. The new transdiagnostic cognitive behavioral treatments: Commentary
for clinicians and clinical researchers. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.11.002
7
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