MA Directed Study. The UP for AUDS. by Katelyn Williams

Running head: APPLICATIONS OF THE UP FOR AUDS 1
Applications of the Unified Protocol for Alcohol Use Disorders
MA Directed Study
Boston University
Katelyn Williams

Applications of the Unified Protocol for Alcohol Use Disorders
Treatment
Module 1: Motivational Enhancement
In order to increase both the patient’s readiness for change and their perceived self-
efficacy to achieve change, treatment with the UP first begins with the implementation of
evidence-based strategies derived from principles and techniques used in Motivational
Interviewing, which have been found to demonstrate greater efficacy in the treatment of anxiety
and emotional disorders by enhancing both client motivation to change, and commitment to
engage in therapy (Buckner & Schmidt, 2009; Korte & Schmidt, 2013; Marcus, Westra, Angus,
& Kertes, 2011). Given Tony’s recognition of his problems regarding his drinking and frequent
experiences of social anxiety and panic-related symptoms, the first aim of module 1 was to
engage Tony in the process of Decisional Balance, so as to help him explore and resolve any
remaining ambivalence that he might have in regards to changing his behavior and committing to
therapy. Specifically, by having Tony list both the pros and cons of his use of alcohol and
maladaptive coping strategies for managing his anxiety, the goal of this technique is to help the
client develop discrepancy between where they currently are and where they want to be, with the
role of the therapist in this process being to “tip the scale” in favor of change through the use of
open-ended questioning and summarization techniques designed to elicit reflection and self-
motivational statements by the client. By referring to the costs and benefits listed by Tony for
both changing and not changing his behavior, the following is an example of how these
approaches might be used:
THERAPIST: So, you noted that for your romantic relationships and friendships, your avoidance of, as
well as your use of alcohol in, social situations has proven to be both advantageous and
disadvantageous to you in the past. Can you tell me a little more about this? (e.g., use of an
open-ended question)

Client: Yeah, so about 2 months after my girlfriend and I broke up, a friend of mine from work asked
to set me up with a close friend of his who he thought I would really hit it off with. After
seeing a picture of her and hearing more about her, I thought she was very attractive and
interesting, and told him that he could give her my number.
THERAPIST: And did you two go on a date?
Client: Well, we were supposed to meet up for dinner when I got out of work, but as I was walking
towards the restaurant that night, I suddenly started to feel very anxious at the thought of
possibly doing something embarrassing – like spilling my water, or saying something dumb.
And then, right as I was about to walk into the restaurant, my hands started to tremble and I
could feel my heart pounding through my chest, which made me experience even more
anxiety at the thought of possibly embarrassing myself by having a panic attack in front of
my date; so instead of going into the restaurant, I left and went home.
THERAPIST: Tell me, what we were the advantages and disadvantages of your use of avoidance in
this situation? (e.g., use of an open-ended question)
Client: After I left, I immediately experienced a sense of relief from my anxiety; however, since then,
my coworker has refused to talk to me out of anger for standing his friend up, and in the
subsequent dates that I have gone on, I have yet to meet anyone with as much “relationship
potential” as the woman who I stood up that night.
THERAPIST: In describing your drinking patterns, you noted earlier that your use of alcohol has
greatly increased since you’ve started dating again, and you also listed a number of ways in
which your drinking has served to both prevent and cause embarrassment for you in these
situations. Can you elaborate a bit more on this for me?
Client: Well, at first, my drinking really helped me with managing the anxiety that I would
experience on first dates; however, because of the tolerance that I’ve come to develop for
alcohol overtime, I now have to drink until I’m intoxicated in order to take that same edge
off, which has resulted in me having to pay extremely expensive cab fairs to get home from
dates, and has also caused me to do a lot of embarrassing things during dates, such as spilling
my water or slurring my speech.
THERAPIST:So, from what you’ve told me, it sounds as though you’ve lost more than you’ve gained
from you’re use of avoidance and alcohol in responding to feared social situations and
physical sensations. For instance, although your avoidance in this scenario allowed you to
avoid potentially having a panic attack and embarrassing yourself, it additionally prevented
you from actually going on a date with a really great woman, and also caused you to loose

your closest friend at work. Furthermore, while your use of alcohol initially served to relieve
some of the anxiety you experienced in social situations, because you now have to drink
more and more in order to experience the same anxiolytic effects from alcohol, it seems as
though your drinking has now become not only a financial strain, but has also caused you to
experience greater feelings of embarrassment and anxiety in social situations. Would you
agree? (e.g., use of a summary statement favoring change)
Client: No, you’re completely right, my drinking and avoidance isn’t really helping me out in the
long run.
Upon demonstrating motivation to change and committing to therapy, the therapist and
Tony then collaboratively worked together to develop an action plan for guiding therapy, which
was based upon a functional analysis of Tony’s problem behaviors, his personal values, and his
expressed goals for treatment. Because of his hesitation to give up drinking completely, a
controlled-drinking model was used for treating Tony’s alcohol dependency, which in research,
has demonstrated to be at least as effective as alternative abstinence models used in the treatment
of alcohol addiction (Marlatt, Larimer, Baer, & Quigley, 1993; Sanchez-Craig et al., 1984). On
the basis of the low-risk drinking guidelines established by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA), it was agreed that one of Tony’s long-term goals for therapy
would be to reduce his alcohol consumption to a weekly limit of 14 drinks, for which a daily
limit of 1-4 drinks was set. In addition to reducing his drinking, Tony further specified that his
primary goals for treatment were to (a) eliminate his social anxiety, (b) learn how to manage
physiological experiences of anxiety and panic without the use of alcohol or avoidance, (c)
increase his sense of self-control, and (d) overcome his agoraphobic fear of driving.
Module 2: Psychoeducation and treatment rationale
During the psychoeducation portion of therapy, the therapist first provided Tony with an
overview of the rationale for treatment with the UP, explaining to Tony that the overarching aims
of therapy would be to help him develop a greater awareness and acceptance of both positive and

negative emotional experiences, while also teaching him how to confront, experience, and
respond to these emotions in a more adaptive way. After introducing Tony to the concept of
emotion-driven behaviors (EBDs), the following discussion is an example of how the therapist
illustrated to Tony the adaptive and functional importance of his recently reported feelings of
increased anxiety and depression.
THERAPIST: In discussing the rationale for treatment in our last session, I introduced you to the
concept of emotion-driven behaviors. Can you tell me again what we said these were?
Client: Yeah, we talked about how EDBs are action tendencies or motivated behaviors that naturally
occur in response to emotional states; and I think you also mentioned that EDBs can have
both adaptive and maladaptive purposes.
THERAPIST: Very good. Well today, we’re going to extend upon this definition a bit by first
exploring the functional importance of emotions such as anxiety and depression for motivating
adaptive EDBs.
Client: But wait, aren’t those the emotions that have been contributing to my problems?
THERAPIST: No, as we’ll discuss later, it’s how you’ve been responding to these emotional
experiences, not the emotions themselves that has been contributing to your problems. Now, I
know this might seem a bit counterintuitive, but try to roll with me. How can experiences of
fear or anxiety serve to motivate functional EDBs?
Client: Okay. I remember back in science class learning about the fight or flight instinct. Does it have
anything to do with that?
THERAPIST: Yes, it has a lot to do with that actually. Now, how about depression or feelings of
sadness? Is there anything adaptive about these emotions?
Client: Well, I guess that without the ability to experience sadness, we might not be as driven to
demonstrate compassion towards others. For instance, the other day as I was watching
TV, a commercial about these impoverished children in Africa came on, and the sadness
that I experienced while watching it motivated me to make a donation to the non-profit
organization supporting them.
THERAPIST: That’s a great example. As you’ve so aptly pointed out, even though negative
emotions such as anxiety and depression can be experienced as uncomfortable or

threatening, we still need to experience these emotions because they serve to motivate
adaptive, functional behaviors for promoting the survival and well-being of both
ourselves and others.
Upon demonstrating the adaptive, functional nature of emotions, the next phase of
psychoeducation with the UP entails: (1) introducing the client to the three-component model of
emotional experience, explaining to them how physiological sensations, cognitions, and
behaviors serve to contribute to both the development and maintenance of emotional disorders,
(2) presenting the client with the ABCs (antecedents, behaviors, and consequences) of emotional
experience, and (3) asking the client to track these experiences by engaging in self-monitoring
throughout the week. Although self-monitoring is used continuously throughout treatment for
tracking the patient’s progress and increasing their acceptance of the adaptive, functional nature
of emotions, the particular purpose of self-monitoring during the initial stages of treatment with
the UP is to enhance the patient’s awareness of their own patterns of emotional responding by
helping them to identify the antecedents, behaviors, and consequences associated with these
experiences.
In the current case example, Tony was assigned to keep a diary for 2 weeks, which was
used for tracking (a) the severity and frequency of his urges to drink and alcohol usage, (b) the
severity and frequency of his experiences of anxiety and panic, and (c) his cognitive, emotional,
and behavioral responding to these experiences. By referring to a particularly intense emotional
experience that Tony had reported to having over the course of this two-week period, the
following is an example of how the therapist and Tony collaboratively conducted a “three
systems analysis” of this event, which was later used for helping Tony to identify more adaptive
ways of responding to similar situations in the future.
THERAPIST: In reviewing your self-monitoring forms, I noticed that last Monday, you reported to
experiencing a particularly intense emotional event at work, and I also saw that your drinking

urges and consumption of alcohol on this day were particularly high. Can you tell me a little
more about this?
Client: Yeah, Monday was a bad day, from start to finish. I had to pitch a presentation that day to one
of my company’s biggest accounts, and had been worrying about it all week. Because of my
fear of driving, I decided to take the bus to work because I didn’t want to add to all of the
anxiety that I was already feeling over having to give this presentation; however, the bus was
delayed that morning, and I ended up being late to work. By the time I finally got to the
office, everyone had already been waiting in the conference room for 20 minutes, and my
boss asked me to begin the presentation right away. After an embarrassing struggle trying to
get the projector to work, I began the presentation, and completely bombed it.
THERAPIST: What do you mean by “bombed it”?
Client: Well, at the start of the presentation, I began to think about how everyone was probably
thinking about what a flake I was for being late, and how incompetent I was for not being
able to get the projector working. Then, about 10 minutes into the presentation, I began to
experience dizziness and shortness of breath; so to save myself from the possibility of having
a panic attack and embarrassing myself even more, I decided to cut the presentation short by
skipping over the majority of the remaining talking points.
THERAPIST: Did you experience any relief from your anxiety by doing this?
Client: Well, it helped with immediately relieving the physical components of anxiety that we talked
about, however, by not driving to work that day and by cutting my presentation short, I began
to feel like a total failure and became really depressed, which in turn, increased my urges to
drink that night.
THERAPIST: So, let’s break down this emotional experience by analyzing the antecedents, behaviors,
and consequences associated with it. The antecedent in this situation was having to give a
presentation at work, which as you said, you were very nervous about. Your behavioral
responses to this nerve-wracking event included (1) not driving to work, so as to avoid
increasing the anxiety that you were already experiencing in anticipation of this event, and
(2) cutting the presentation short, so as to avoid your experiences of uncomfortable physical
sensations, as well as the potential of being negatively evaluated by others. Consequentially,
your avoidant behaviors in this situation resulted in increasing your feelings of depression,
and your urges to drink. In addition to these short-term consequences, the long-term
consequence of your behavioral responding in this situation is that, because it allowed you to
successfully avoid having a panic attack, it might serve to further reinforce your maladaptive-
use of avoidance in responding to similar experiences of intense emotion in the future.

After helping Tony develop an understanding of the nature, precipitation, and
maintenance of emotional disorders, the therapist then explained to Tony how the remainder of
therapy would be aimed at targeting the maladaptive patterns of emotional responding that have
contributed to both his problem drinking, and the exacerbation of his experiences of anxiety and
depression.
Module 3: Emotion Awareness Training
Given that individuals with anxiety and alcohol use disorders have a tendency to ascribe
negative attributions to emotions associated with uncomfortable experiences such as affective
arousal, distress, and cravings, the first core module of the UP is designed to help the patient
develop a more objective, nonjudgmental, and present-focused awareness of their emotional
experiences, so as to (1) increase their tolerance of negative emotions, (2) reduce the frequency
at which they experience secondary emotions, and (3) increase their preparedness and ability to
implement skills introduced later in therapy. By expanding upon the information previously
presented to the client about EDBs in module 2, the therapist explains that it is not the experience
of intense emotion itself that is problematic, but the way in which the client reacts to this
experience. It is then explained to that client that, before they can learn how to respond more
adaptively to experiences of intense emotion, they must first learn how to objectively assess,
accept, and anchor these experiences within the present context in which they occur.
Using the previous discussion presented in module 2 as a point of reference, the
following is an example of how the therapist first demonstrated to Tony the ways in which his
emotional responding in this situation had served to exacerbate his experiences of emotional
distress and his urges to drink, and then explained to him how adopting a nonjudgmental,

present-focused awareness and acceptance of these negative emotional experiences in the future
would help to make them more manageable and less intense.
THERAPIST: In starting our session today, I’d like to refer back to the thoughts that you expressed to
having in response to the intense emotional experience that you had at work last Monday.
Specifically, I’d like to know why your experiences of anxiety and panic that day made you
feel like “a total failure”.
Client: Because, I can’t do the most basic things like driving my car to work, or giving a simple
presentation without breaking down and having a panic attack. I just feel like anxiety is
something that keeps me from being a normal person, who can do normal, everyday-things
without being scared.
THERAPIST: But remember, as we discussed earlier, anxiety is a normal, adaptive emotion that
everyone experiences, so the fact that you experience anxiety is actually an indication that
you are a normal person, just like everyone else.
Client: Okay, well if I am normal for experiencing anxiety, then why is it that I have such difficulty
doing normal things like everyone else?
THERAPIST: The cause of your problems isn’t the fact that you experience intense emotions such as
anxiety; it’s how you’ve been judging and responding to these experiences that has been
causing you difficulties. For example, look at the sequence of events that transpired as a
result of you judging your experiences of anxiety as “abnormal”. During your presentation,
holding this judgment firstly caused you to become preoccupied with the physiological
sensations of your anxiety, causing you to become even more worried and panicked at the
thought that the people around you might take notice and evaluate you negatively. As you
noted later on, because you judged your experience of anxiety as being abnormal, you began
to feel like a failure over not being able to finish the presentation, which in turn, contributed
to your experience of a secondary emotion – depression. Subsequently, your judgment of this
negative emotional experience increased the intensity of your cravings for alcohol, which led
you to drink excessively that night; however, as opposed to relieving the distress that you
were experiencing, your drinking only served to prolong it by causing you to feel even more
depressed over your lack of control.
Client: Wow, that’s a really vicious cycle.
After helping Tony understand how taking a nonjudgmental, momentary, and mindful
approach to experiences of uncomfortable emotions in this situation would have instead served

to decrease the intensity and duration of his distress, the remainder of the session was spent
having Tony engage in a number of therapist-guided training exercises, including: (1) a present-
focused emotional awareness exercise, which allowed Tony to practice anchoring himself in the
present moment; (2) a body scan exercise, which was used for fostering Tony’s mindfulness
skills; (3) an emotion induction exercise, which allowed Tony to practice nonjudgmental,
present-focused awareness while listening to an emotionally-evoking song, and (4) a breathing
exercise, which taught Tony how to condition his breath as a cue for eliciting present-focused
awareness. Because of the difficulties that patients’ with substance use disorders experience in
identifying and interrupting automatic appetitive responses towards alcohol, mindfulness was
also incorporated as an intervention for helping Tony to develop a greater awareness and
acceptance of his experiences of cravings, which in research, has been demonstrated to modulate
the effect of unconscious appetitive urges to drink by helping patients cultivate a more accepting,
present-focused, nonjudgmental attitude towards these urges (Ostafin & Marlatt, 2008).
So as to strengthen their emotional awareness skills outside of therapy, patients are asked
to repeat these exercises throughout the week by completing a supplementary homework form.
In addition to these exercises, Tony was also instructed to engage in “urge surfing” exercises
(Marlatt, 1994), which were designed to enhance his acceptance of uncomfortable experiences of
cravings by increasing his awareness regarding the transient nature of these experiences.
Module 4: Cognitive Appraisal and Reappraisal
Similarly to traditional forms of cognitive therapy, the main goal of the cognitive
reappraisal techniques implemented in the fourth (and second core) module of the UP is to help
patients develop more flexible ways of thinking about their experiences of intense emotion, by
teaching them how to identify, interrupt, and reappraise maladaptive cognitions and core

automatic appraisals that serve to contribute to their problems. Prior to implementing these
techniques, the therapist first begins by introducing the client to the concept of cognitive
appraisal, explaining to them that personal interpretations of an event (1) are largely dependent
upon the stimuli that a person chooses to attend to in any given situation [and thus, can be
reappraised and interpreted in a number of different ways], (2) serve to reciprocally impact
emotions and behaviors, (3) often occur automatically and outside of conscious awareness as a
result of previously learned associations, and (4) can evolve into “thinking traps” when
negatively biased overtime.
Given the rigidity and negativity that typically characterize the thinking patterns of
individuals with both emotional and alcohol use disorders, the first appraisal technique
implemented in this module is an in-session “ambiguous picture exercise”, which is used to
illustrate to the client the many alternative appraisals that can be drawn from a situation when all
available information is attended to; in sum, this exercise entails instructing the client to identify
their initial automatic appraisal of an ambiguous picture, and to then brainstorm several
interpretations that could instead be attributed to the depicted image. After demonstrating the
multiple perspectives that can be taken in interpreting a situation, the remainder of module 4 is
then devoted to helping the patient identify the core automatic appraisals and cognitive biases
responsible for driving their own emotional responding, which is done through the integrated-use
of (1) Socratic questioning, (2) the downward arrow technique, and (3) antecedent-based
appraisal strategies aimed at targeting the two core thinking traps of “probability
overestimation” (e.g., the tendency to jump to conclusions) and “catastrophizing” (e.g., the
tendency to assume the worst-case scenario). Although these two cognitive distortions generally
capture the cognitive-affective tendencies of clients with emotional disorders, because alcohol-

dependent individuals also have a tendency to believe that their drinking will elicit anxiolytic
effects or provide social lubrication, “tension-reduction expectancies” should additionally be
addressed as a third core-thinking trap in the treatment of alcohol use disorders with the UP.
As demonstrated by the use of these techniques in the following excerpt, the core
automatic appraisals identified as “drivers” of Tony’s anxiety- and drinking-related behaviors
included his beliefs that (1) his experiences of panic-related sensations constituted a threat of
imminent physical harm, (2) that he was prone to be a failure in life, and (3) that his use of
alcohol served to both ameliorate his anxiety and enhance his social skills.
THERAPIST: Now that you have a better understanding of how maladaptive automatic appraisals can
work to perpetuate emotion-driven behaviors, I’d like for us to use the remainder of this
session to try to identify some of the core thinking patterns that may have driven your
emotional and behavioral responding in the recent experiences that you discussed to having
at work and with dating. Let’s start with the thoughts that were associated with your decision
not to drive to work on the morning of your presentation.
Client: Like I said before, I didn’t want to add to all of the anxiety that I was already feeling over
having to give my presentation by possibly having a panic attack while driving to work.
THERAPIST: Okay, well let’s say you did decide to drive to work that morning and had experienced a
panic attack. What did you think would have happened?
Client: Well, either: (1) I would have possibly passed out and killed myself by crashing my car, or (2)
that the panic attack would have persisted for hours and prevented me from giving my
presentation at work.
THERAPIST: In regards to your first appraisal of your experiences of panic, one core thought that
you just identified in this situation is that, if you had had a panic attack, you might have
died. But tell me, what were you afraid would have happened in the alternative scenario if
your panic attack had persisted and prevented you from giving your presentation that
morning?
Client: Well in that scenario, I would have been afraid that my panic attack would have resulted in
my boss firing me.
THERAPIST: And if you had gotten fired, what would that have meant to you?

Client: It would have meant that I was a failure.
THERAPIST: So, it seems as though another automatic appraisal driving your avoidance of panic-
related sensations in this situation was that, if you had experienced a panic attack while
driving, you would be have been more prone to experiencing failure in your professional life.
Now, let’s try to identify some of the automatic thoughts that were going through your mind
during the presentation.
Client: At the time, I remember thinking how everyone in the room probably thought I was a flake
and incompetent for being late and for not being able to get the projector working. I was also
really nervous of possibly embarrassing myself by fumbling over my words, or having a
panic attack during my presentation.
THERAPIST: Alright, well if you had fumbled over your words or experienced a panic attack in this
situation, what were you afraid would have happened?
Client: I was afraid that everyone in the room would have judged me harshly, and that the social
embarrassment that I would have experienced would have been unbearable.
THERAPIST: And what exactly is it that you find so threatening about being negatively evaluated?
Client: I guess I think that, if others look down on me, it’s just another indication that I’m a failure.
THERAPIST: Okay, so as you’ve just identified, two common appraisals that were responsible for
driving your panic- and phobic-related behaviors in this situation were your fearful
predictions of either experiencing physical harm, or personal failure. Going back to one of
our previous discussions regarding your recent dating experiences, I’d like for us to now try
to identify some of the automatic appraisals that served to contribute to your excessive
drinking in these scenarios. Tell me, why did you think that you needed to have a few drinks
while on these dates?
Client: Well, in addition to helping me relax, I thought that drinking in these situations would also
help me to be more conversational, and less socially awkward.
After helping him identify these core maladaptive appraisals, the remainder of the session
was spent (1) having Tony challenge these appraisals by generating more realistic, alternative
perspectives that could have been taken in these situations, (2) teaching Tony how to counter
future maladaptive appraisals through the use of the previously mentioned antecedent-based

strategies, and (3) assigning Tony with self-monitoring homework for practicing these
reappraisal strategies throughout the week.
Module 5: Emotion Driven Behaviors and Emotional Avoidance
Given the emphasis placed on affective-behavioral modification by empirically supported
models of treatment for individuals with both emotional and alcohol use disorders (Barlow,
2002; Cox & Klinger, 1988), the overall aim of module 5 of the UP is focused on helping
patients to identify, understand, and modify patterns of maladaptive emotion-driven behaviors
(EDBs) and emotional avoidance responsible for contributing to and maintaining these disorders.
In discussing the behavioral component of emotional experience, the therapist first begins by
explaining when and why EDBs can become maladaptive, and how– through the process of
negative reinforcement – they ultimately serve to perpetuate and strengthen experiences of
disordered emotion, despite their ability to provide momentary relief in the face of intense or
uncomfortable emotional experiences. Similarly to EDBs, the therapist also explains how various
types of emotional avoidance strategies – such as subtle behavioral avoidance, cognitive
avoidance, and use of safety signals – all additionally contribute to the dysregulation of
emotional and behavioral responding.
After introducing these concepts and demonstrating the futility of their use in managing
and suppressing experiences of intense emotion, the therapist then helps the patient to identify
typical patterns of EDBs and emotional avoidance that may be contributing to their own personal
experiences of emotional distress and/or problematic drinking; in the current case example, this
was done by referring to an intense emotional event that Tony had reported to experiencing in
the previous week.
THERAPIST: Now that you have a better grasp on how EDBs can become maladaptive and
maintained through negative reinforcement, I’d liked for us to try to identify any maladaptive

behaviors that you might have recently engaged in in response to an uncomfortable
experience of emotion. In reviewing your self-monitoring record from last Friday, I noticed
that your anxiety ratings were particularly high that day, and that your alcohol consumption
was 6 drinks over the maximum limit that you had set for your daily drinking goal.
Client: Yeah, on Friday I had to go to a retirement party, and was really anxious about having to
socialize with my boss and some of the other higher-up executives from work.
THERAPIST: And how did you go about coping with your anxiety in this situation?
Client: Well, I got to the function hall a little early so that I could grab a drink to settle my nerves a
bit before everyone got there.
THERAPIST: And did your anxiety subside by the time everyone arrived?
Client: Not until I had about two more cocktails.
THERAPIST: So, by this time, you were three drinks in. Did you finally feel more comfortable
conversing with others at this point?
Client: I was definitely starting to feel a bit more at ease and was confident enough to start talking to
others.
THERAPIST: Alright, so if your nerves had started to subside by this point, then why did you continue
to drink?
Client: Even if I’m not drinking, I still find it really comforting holding a drink in my hand when I’m
in social situations.
THERAPIST: And why’s that?
Client: Well, I guess for a few reasons. First, I find that holding something helps me from getting
nervous and fidgety while talking to others. It also helps me feel less anxious knowing that I
have alcohol right there in the event that I do begin to experience anxiety. In the past, I’ve
additionally found that if I’m holding an empty glass, it gives me a good excuse to leave a
conversation to “go freshen my drink” if the conversation starts to lag, or if I get too nervous
and can’t think of anything to say.
THERAPIST: So from what you’ve just told me, your drinking in this situation constituted not only an
EDB, but an emotional avoidance strategy as well. Firstly, your use of alcohol in this
situation constituted a coping EDB, as well as an escape EDB, in that it firstly allowed you to

dampen the intensity of the anxiety that you were already experiencing in this situation, and
secondly, because it provided you with a means of escaping from this anxiety after it had
occurred. As a safety behavior,your drinking here further served to function as an emotional
avoidance strategy in that it also allowed you to modify the social situation in a manner that
prevented you from experiencing any further feelings of anxiety. However, as I mentioned
earlier, although your use of alcohol in this situation might have provided you with short-
term relief from your anxiety, in the long-run, this strategy will only serve to maintain and
heighten you social phobia by reinforcing not only your use of alcohol in social situations,
but also your perception of social situations as being anxiety provoking – which in turn, will
prevent you from learning new, more adaptive associations that would serve to make these
anxiety-provoking experiences more tolerable and manageable without the use of alcohol.
After helping the patient to identify their usual patterns EDBs and emotional avoidance,
the remainder of this module is spent: (1) teaching the client how these patterns can be countered
by engaging in (a) behaviors incompatible to their EDBs, and (b) activities that evoke emotions
that they currently avoid; and, (2) assigning the client with self-monitoring homework so that
they can begin implementing and practicing these countering strategies throughout the week.
Module 6: Awareness and Tolerance of Physical Sensations
Because of the strong emotional reactions that physiological sensations of anxiety and/or
craving often produce for individuals with emotional and substance use disorders, the overall aim
of module 6 of the UP is focused on increasing both the client’s awareness and tolerance of these
sensations through the use of interoceptive exposure (IE) exercises. Typically, this module is
completed over the course of one session, during which the therapist (1) elaborates on both the
role of physical sensations as a core component of emotional experiences, and the rationale for
provoking these sensations, and (2) engages the client in a list of “symptom induction exercises”,
which are tailor-designed to elicit physiological sensations relevant to the client’s experiences of
disordered emotion. As demonstrated by the following excerpt, a combination of disorientation
and hyperventilation IE exercises were used for inducing the physical sensations typically
associated with Tony’s experiences of anxiety and panic.

THERAPIST: In order to help increase both your awareness and tolerance of the physical sensations
associated with your experiences of anxiety in social and agoraphobic situations such as
driving, I’d like for us to practice two exercises that are specifically designed to induce the
symptoms of dizziness and shortness-of-breath that frequently accompany your panic attacks.
For the first exercise, I’d like for you to remain seated in your chair, and roll your head in
circles for one minute like this [demonstrates disorientation exercise to client], and when
you’re done, I want you to rate, on a scale of 0 (Not at all) to 7 (Very much), the intensity,
distress, and similarity of the dizziness induced by this exercise relative to the usual
experiences of uncomfortable emotions that this sensation evokes for you during an actual
panic attack.
Client: Okay [completes disorientation exercise].
THERAPIST: Can you tell me what sensations you noticed during that exercise?
Client: I experienced really uncomfortable sensations of light-headedness and vertigo. It felt as
though the whole room was spinning out of control.
THERAPIST: And on a scale of 1-7, how would you rate the intensity and distress of these sensations?
Client: Probably a 7 for both.
THERAPIST: And similarity?
Client: If I had experienced that kind of dizziness while driving, it would have been incredibly intense
and distressful because I would have been afraid of possibly crashing; but because I
experienced it here while sitting in a chair, I’d say it only rated about a 4.
THERAPIST: Now, I’d like for you to repeat this exercise two more times, while nonjudgmentally
paying attention to the sensations alone.
Client: Alright [completes disorientation exercise twice].
THERAPIST: In these subsequent exercises, did you notice any changes in the intensity and distress
of these sensations?
Client: Actually, yes. When I stopped evaluating the experience as being uncomfortable and just
focused on the symptoms of dizziness alone, I noticed that the intensity and distress of the
experience decreased each time.

Given the efficacy that interoceptive exposure techniques have demonstrated in
increasing alcohol-dependent individuals’ tolerance of uncomfortable physiological and
emotional sensations associated with experiences of withdrawal and craving (Otto, O'Cleirigh, &
Pollack, 2007), an additional imaginal IE exercise was also used for inducing physical sensations
typically associated with Tony’s experiences of anxiety and craving during social situations.
Procedurally, this exercise was carried out in a similar manner as the previously conducted
disorientation and hyperventilation exercises, but instead entailed having Tony imagine himself
in three different anxiety-provoking social scenarios, during which a pitcher of beer was placed
on the therapist’s desk, so as to simultaneously expose Tony to both the sight and smell of
alcohol throughout the exercise.
Upon completing these exercises, module 6 of the UP concludes by assigning the client
with a list of relevant IE exercises to complete throughout the week, for which they are again
instructed to (1) describe and rate the intensity of the physical symptoms they experience, (2)
rate the level of distress they experience during the task, and (3) rate the degree of similarity of
the experience to their naturally occurring symptoms. In the current case example, Tony’s list
included (1) a set of hyperventilation, disorientation, straw-breathing, and running exercises,
which were designed to induce physiological sensations associated with both his agoraphobia
and social phobia, and (2) a set of social exercises, which required him to abstain from drinking
alcohol in anxiety-provoking social scenarios so as to increase his awareness and tolerance of
uncomfortable experiences of craving.
Module 7: Interoceptive and Situational Exposure
In order to further increase their awareness and tolerance of uncomfortable internal and
external experiences of intense emotion, clients in the final core module of the UP continue to

engage in the previously learned interoceptive exposure exercises introduced during module 6,
and additionally learn how to apply new, more adaptive emotion-regulation strategies by
gradually engaging in symptom-specific situational emotion-exposure exercises. Procedurally,
this module is typically carried out over the course of four to six sessions, during which the client
is repeatedly exposed to a range of typically-avoided situations in a graded, bottom-up manner
on the basis of an emotional avoidance hierarchy (EAH) designed by both the therapist and the
client. After discussing the rationale of engaging in emotion exposure and explaining its
necessity as a mechanism of action for change, the therapist first begins by guiding the client
through a series of in-session exposure exercises corresponding to situations listed on the bottom
of the client’s EAH, and further assigns them with the task of completing similar exposures
throughout the week, with subsequent sessions being spent reviewing their completion of these
tasks, and gradually engaging them in more difficult exposure exercises each week.
Given the challenges posed by the mutually reinforcing relationship between social
anxiety and alcohol use disorders, two recommendations should be considered when conducting
this module with social phobic and alcohol-dependent individuals. Firstly, because parallel
approaches to treating social anxiety and alcohol use comorbidity have been observed to produce
poorer treatment outcomes (Randall, Thomas, & Thevos, 2001;Schadé et al., 2005), situation
exposures utilized during this module should be implemented in a synthesized manner so as to
provide guidance for managing the reinforcing interactions that serve to maintain these two
disorders. As aptly noted by Stapinski et al. (2014), because individuals with social phobia use
alcohol as a means for managing their anxiety, if exposures are not designed in a manner that
addresses these disorders concurrently, increased exposure to social situations may instead serve
to exacerbate the client’s use and dependence on alcohol. Secondly, because even infrequent

alcohol use has been found to disrupt the various benefits associated with graded exposure (Foa
& Kozak, 1986; Wells et al., 1995), alcohol-dependent clients are further encouraged to abstain
from drinking during this module, so as to allow for extinction-learning to occur.
For Tony, situation exposures were explicitly designed in a hierarchical, graded manner
for concurrently targeting his use of alcohol, as well as his fears of social situations, panic-
related sensations, and driving. In addition to gradually exposing Tony to feared and avoided
situations, in-session exposures also allowed Tony to practice applying the skills he had learnt
thus far to these situations, and also gave him the opportunity to develop a plan for managing
experiences of anxiety and craving that might be elicited by assigned exposures to various high-
risk situations in the coming week(s). As depicted in Table 1, one exposure assignment near the
top of Tony’s hierarchy was to attend a poker night that his friend had invited him to, which was
designed to target several of Tony’s fears at once by requiring that he: (1) drive his car to the
game, and then back home, (2) practice his drink refusal skills, and (3) socialize with a number
of people who he did not know very well.
THERAPIST: Before we begin with the exposure exercises planned for today’s session, I’d like for us
to start out by discussing the exposure task that you were assigned to complete for last
week’s homework. The first part of your assignment was to confront your agoraphobic fears
by driving to your friend’s poker game. Can you tell me about the experiences that you had
before, during, and after the car ride?
Client: Well, I was obviously really anxious about having to drive, and started procrastinating a bit to
put off having to leave. When I finally did manage to make it to the car, I began to
experience some panic symptoms, like racing heart and shortness of breath. So I gave myself
two minutes to practice some of the mindfulness techniques that you taught me, and although
it didn’t entirely make the anxiety go away, it did help me enough to get the car going and to
drive to my friend’s house.
THERAPIST: That’s great! In this scenario, you did two really important things. Firstly, you were able
to identify your use of procrastination as an avoidance strategy, and you were further able to
use mindfulness as a means for increasing your tolerance to the anxiety that you were

experiencing at the time. Now tell me, did you encounter any experiences of anxiety or
craving once you got to your friend’s house?
Client: For the first hour it was pretty bad. Before we started playing, everyone was spread out
across the kitchen and living room socializing, and because I only knew one person there, I
felt really out of place and was nervous that I looked awkward. It also didn’t help seeing
everyone else drinking, and having to stand around with nothing in my hand made me feel
even more awkward and exposed.
THERAPIST: How did you go about managing the anxiety and cravings you were experiencing at this
point?
Client: I went to the bathroom for about 10 minutes to collect myself.
THERAPIST: And how did you do that?
Client: Well, I engaged in urge surfing to ride out the cravings I was experiencing, and I also
practiced constructive self-talk while looking in the mirror, which helped to bring my anxiety
down a bit. When I went back out, my friend asked if I wanted a drink, and when I refused, I
started to feel really self-conscious and thought that the other guys around me might judge
me for not drinking; but then, this other guy next to me said he wasn’t drinking either
because he was training for a triathlon, which kind of served as some objective feedback for
challenging my cognition about being negatively evaluated for not drinking.
THERAPIST: Wow, that’s really great you were able to hear that. So, at this point, were you starting
to feel a bit more comfortable?
Client: Once we all sat down at the table to play, I started to feel more comfortable because it gave
me more of a designated spot amongst the group so that I didn’t have to stand around
awkwardly anymore. Sitting between my friend and Rick – the guy training for the triathlon –
also helped to reduce my experiences of craving and anxiety as well.
THERAPIST: How did you do conversationally?
Client: Well, Rick and I actually ended up hitting it off really well. And by talking to both him and
my friend, I was able to get into conversations with the people sitting next to them too.
THERAPIST: Did your ability to socialize with others without alcohol in this situation serve to
challenge any of your former beliefs about your use of alcohol?

Client: It definitely challenged a lot of my beliefs about the advantages of drinking in social
situations. Not only did I find that I was able to get along with people well without drinking,
but I also found that, in comparison to everyone else at the table, not drinking in this situation
also helped with my performance in the game, and I ended up winning $100, which all the
guys seemed pretty impressed with; and, they even asked me to come back next week to play
with them again.
THERAPIST: That’s incredible! So once you left, did you experience any anxiety during your drive
home?
Client: Actually, my drive home ended up turning into a social exposure exercise as well. One of the
guys from the game was too drunk to drive home, and because of all the confidence that I had
just experienced, I volunteered to give him a ride. Although I would have normally
experienced anxiety in a situation like that, at the time, I was actually feeling really
empowered and like I had control over my life, because for once, I finally wasn’t the guy
who got too wasted to drive.
THERAPIST: Wow. You really made some huge strides with this exposure.
Module 8: Relapse Prevention
Treatment with the UP concludes with a final psychoeducation module focused on
identifying and preventing high-risk situations for relapse, during which the therapist reviews the
treatment principles and strategies learnt during therapy, acknowledges the client’s treatment
progress, and provides the client with recommendations for areas that could use further
improvement. In order to maintain treatment gains, the client and the therapist additionally work
together to develop a timeline, as well as exposures to help the client in meeting their long-term
goals after therapy. The client is also reminded that periodic experiences of intense emotion are
inevitable, and are not necessarily an indication of relapse; they are then further informed that, if
needed, additional booster sessions can be provided in the future for troubleshooting any
problems that may arise.
In the current case example, Tony’s progress was reviewed by having him re-rate the
perceived difficulty of situations listed on his emotion avoidance hierarchy, which relative to his

initial ratings of these situations, were significantly lower, particularly for previously avoided
and feared situations involving driving. Given that social situations have been shown to precede
nearly 40% of relapses (Monti, Gulliver, & Myers, 1994), the Situational Competency Test
(Chaney, O'Leary, & Marlatt, 1978) was used for identifying high-risk drinking and social
situations, as well as weaknesses in Tony’s skill set for managing these situations. Although
Tony had made great progress throughout treatment, he still struggled with intense anxiety and
cravings for alcohol during social interactions with women; to address these issues, part of
Tony’s long-term goal plan was to continue engaging in social exposure exercises involving low-
drinking risks (e.g., getting coffee with a female co-worker during a lunch break), so as to further
develop the remedial social and dating skills that he had been taught earlier during treatment. For
individuals with social anxiety and alcohol use disorders, because lack of social support has
consistently been found to be one of the strongest predictors of relapse after treatment (Beattie &
Longabaugh, 1999; Dobkin, Civita, Paraherakis, & Gill, 2002; Kushner et al., 2005) – and
because many of the interests, social interactions, and activities of these individuals prior to
treatment typically involved drinking, two other long-term goals established for Tony included,
(1) enlisting a group of family members and close friends to support and encourage him with
maintaining his treatment gains, and (2) enrolling in weekly spinning classes, which was an
activity that was both incompatible with drinking, and would allow him to socialize with new
people.
Clinical Outcomes
As evidenced by his self-reported symptoms of anxiety and alcohol use (see Table 2),
Tony responded well to treatment using the UP, and experienced marked decreases in diagnostic
severity across all disorders, as well as improved psychosocial functioning. Clinically, Tony

experienced dramatic decreases in his anxiety, depression, and stress, with his DASS-A, -D, and
–S severity scores decreasing from the range of extremely severe at pre-treatment, to normal
ranges at post-treatment. Tony’s HAM-A and HAM-D scores for anxiety and depression also
decreased from moderate severity levels at pre-treatment, to normal levels at post-treatment as
well. Using a controlled-drinking model, Tony’s self-reported alcohol use similarly decreased
during treatment with the UP, with his ADS scores shifting from the upper-end of the second
quartile range indicating intermediate alcohol dependence at pre-treatment, to the bottom-end of
the first quartile range indicating low alcohol dependence at post-treatment. As indicated by his
DrInC scores, Tony further reported to experiencing fewer drinking-related consequences at the
time of post-treatment than he had reported to experiencing at pre-treatment.
Functionally, Tony was able to meet a number of his long-term treatment goals, which
included reducing his alcohol consumption to an average of 12-14 drinks per week, and
increasing his perceived self-efficacy in his ability to manage experiences of anxiety without the
use of alcohol or avoidance. By the end of treatment, Tony’s engagement in social interactions
had significantly increased, and he reported to feeling “like a much more confident person”,
which was noticeably evident in both his demeanor and presentation at the time of termination.
On the basis of Tony’s post-treatment assessment scores, Tony’s clinician estimated that his CSR
for a principal diagnosis of an AUD had dropped from a clinical level of 6 to a subclinical level
of 3, and that his comorbid diagnosis of social anxiety disorder was in partial remission with an
estimated CSR of 1.

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Table 1
Tony’s Emotion Avoidance Hierarchy (EAH)
Steps Predicted
Difficulty
(0-8)
Drive to a friend’s wedding, and attend
without drinking alcohol. Make an effort to
talk to a woman sitting at the same table,
and ask her to dance
8
Go on a blind coffee date with a woman; drive
car to and from date.
8
Attend a friend’s poker night, and practice
assertive drink refusalskills when offered a
beer; drive to and from game.
7
Initiate conversation with a woman at the gym 7
Induce panic-related sensations via straw-
breathing, and then rehearse a presentation
for work in front of therapist and an
audience of confederates (in session)
6
Drive to bar with therapist to practice ordering
a non-alcoholic drink
6
Engage in therapy session with therapist while
driving car after inducing panic-related
sensations via straw-breathing
5
Make small talk with a female cashier while
checking out at the grocery store
4
Induce panic-related sensations via straw-
breathing and disorientation exercises,and
then role-play having a conversation with a
woman on a date (in session)
3

Table 2
Baseline and post-treatment descriptive data
Assessment Baseline Post-Tx
ADS 27 ------------------------
ASI 20 9
DASS-A 24 0
DASS-D 40 0
DASS-S 38 0
DrInC 31 ------------------------
HAM-A 18 5
HAM-D 11 6
Principal Diagnosis CSR 6 3
Notes:ADS, Alcohol Dependence Scale; ASI, Anxiety Sensitivity Index; DASS-A,Depression
Anxiety Stress Scales- Anxiety subscale; DASS-D Depression Anxiety Stress Scales-
Depression subscale. DASS-S, Depression Anxiety Stress Scales- Stress subscale. HAM-A,
Hamilton Anxiety Rating Scale; HAM-D,Hamilton Depression Rating Scale (range 0-23).
CSR, Clinical Severity Rating from the Anxiety Disorders Interview Schedule.

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