Components of the UP
The UP consists of 7 modules that target key aspects of emotional processing and regulation of emotional experiences. Although the modules were designed to build on one another, they can also be flexibly administered depending on what seems clinically useful for a particular patient. Throughout these modules, the goal is to help replace maladaptive emotion-regulation strategies with more adaptive, functional strategies to increase overall functioning.
Modules 1 and 2, psychoeducation and motivation enhancement, focus on providing the patient with an understanding of the adaptive nature and function of emotions. In addition, these modules promote a sense of self-efficacy and motivation to engage in treatment.
Module 3, emotional awareness training, teaches patients to observe the interaction of thoughts, feelings, and behaviors in emotional experiences, with a particular emphasis on grounding this awareness within the current context in which the emotions occur.
In Module 4, cognitive appraisal and reappraisal, patients are taught to identify habitual use of maladaptive, automatic appraisals and the role these appraisals play in emerging emotional experiences. In a traditional cognitive-therapy format, patients are taught reappraisal skills, with the goal of increasing cognitive flexibility. Reappraisal is a strategy used to help patients develop more flexible thinking patterns in response to their emotions, thereby altering the trajectory of the emerging emotional experience.
In Module 5, countering emotion-driven behaviors and emotional avoidance, specific behaviors that perpetuate maladaptive emotional response are examined. Individuals with emotional disorders often attempt to modify situations in order to dampen the intensity of their emotional experience, particularly if that situation is one they are unable to avoid. Thus, they carry “just in case” items with them into feared situations (eg, antianxiety medication, cell phone) to make their experience more manageable, or they can engage in other behaviors (eg, not maintaining eye contact) to avoid the emotional experience.
We refer to action tendencies, or motivated behavioral responses associated with emotions, as emotion-driven behaviors (EDBs).10-12 While EDBs are often adaptive under certain circumstances (eg, immediate danger triggers fear, which elicits an escape response), they become maladaptive when they occur indiscriminately or are inappropriate for the situation (eg, fear triggered by perceived danger associated with having a panic attack elicits the same escape response). Thus, another focus of Module 5 is on working with patients to identify maladaptive EDBs and teach patients how to act opposite (by implementing incompatible behaviors) in order to alter their emotional experiences.
Module 6, interoceptive and situational exposures, focuses on exposure to both internal and external emotional triggers, which provides patients opportunities to increase their tolerance of emotions and allow for new contextual learning to occur. Interoceptive exposure, or exposure to uncomfortable physical sensations, is used to help patients identify and tolerate physiological aspects of emotional experience. Situationally based exposures are similarly used to increase emotional tolerance, allow for the adoption of adaptive emotion regulation strategies, and introduce new contextual experiences. Here the focus of the exposures is the emotional experience itself that arises in situations beginning with exposure to nonspecific (or clinically irrelevant) emotion cues and progresses toward exposure to situations that evoke stronger or more uncomfortable emotions.13
The seventh and last module, relapse prevention, emphasizes the natural ebb and flow of emotional experiences, and reminds the patient that a recurrence in the experience of anxiety or other mood disturbances does not indicate relapse. Patients are reminded that the goal is not to eliminate emotions but rather to respond to emotions in a more adaptive, functional way.