Journal of Cognitive Psychotherapy: An International Quarterly

Volume 23, Number 1 • 2009

The Transdiagnostic Perspective

on Cognitive-Behavioral Therapy for
Anxiety and Depression: New Wine
for Old Wineskins?

David A. Clark, PhD

University of New Brunswick

Steven Taylor, PhD

University of British Columbia

Transdiagnostic cognitive-behavioral therapy (CBT) for anxiety and depression has been of
growing interest in psychotherapy research. In this article we discuss several fundamental
issues raised by contributors to this special issue on transdiagnostic CBT for emotional dis-
orders. Although researchers have tended to assume that interventions are transdiagnostic
because they are labeled as such, the actual boundary between transdiagnostic and disorder-
specific treatments may be far less clear than previously acknowledged. Nevertheless, there
are many reasons to advocate for greater attention to a transdiagnostic perspective, not the
least being the large shared variance in the emotional disorders, which is often overlooked
in contemporary disorder-specific CBT protocols. Evidence of the efficacy of transdiagnostic
CBT for anxiety and depression is limited, and issues facing comparative outcome and pro-
cess studies are discussed. The article concludes by suggesting a programmatic framework for
advancing a theory-driven, empirically based psychotherapy research agenda that could lead
to the development of a truly integrated, transdiagnostic CBT for anxiety and depression.

Keywords: transdiagnostic; cognitive-behavioral therapy; anxiety; depression; psychotherapy;

emotional disorders

N
umerous randomized controlled trials published over the last 3 decades have shown
that cognitive-behavioral therapy (CBT) is highly effective in treating various anxiety
and mood disorders (Barlow, 2004; Butler, Chapman, Forman, & Beck, 2006; Hollon,
Stewart, & Strunk, 2006). These interventions adopt a disorder-specific perspective, with many
treatment protocols rooted firmly in cognitive models that emphasize cognitive constructs con-
sidered unique to these disorders. Examples of this theory-driven, manualized disorder-specific
treatment approach include cognitive therapy for depression (Beck, Rush, Shaw, & Emery, 1979),
panic disorder (D. M. Clark, 1986, 1988), posttraumatic stress disorder (D. M. Clark & Ehlers,
2004; see also Taylor, 2006), and obsessive-compulsive disorder (D. A. Clark, 2004; Rachman,
1998; Salkovskis, 1989). The success of CBT for anxiety and depression, however, has not been

60 © 2009 Springer Publishing Company

DOI: 10.1891/0889-8391.23.1.60
 Transdiagnostic Perspective on Cognitive-Behavioral Therapy 61

without controversy and debate. Three prominent problems have appeared: (a) failure to dem-
onstrate a significant additive advantage of cognitive ingredients over “purely” behavioral inter-
ventions, (b) difficulty in establishing cognitive mediation, and (c) neglect of common or shared
features across disorders.
Findings from comparative outcome studies and component analyses of CBT for anxiety
and depression suggest that cognitive therapy is no more effective than “purely” behavioral
interventions, and specific cognitive interventions like cognitive restructuring or empirical
hypothesis-testing do not provide incremental clinical effectiveness when compared to behav-
ioral interventions like graded in vivo exposure or behavioral activation (e.g., Dimidjian et al.,
2006; Dobson et al., 2008; Foa et al., 2005; Hofmann, 2004; Jacobson et al., 1996; Öst, Thulin, &
Ramnerö, 2004; Whittal, Thordarson, & McLean, 2005; see also Longmore & Worrell, 2007). In
addition, it has been difficult to show that clinical improvement with cognitive therapy is due
to change in dysfunctional cognitive content or processes. Not only has the study of cognitive
mediation proved difficult to investigate (DeRubeis, 2008), but other noncognitive interventions
including various types of drugs can significantly reduce negative cognition (e.g., DeRubeis et al.,
1990; Meyer et al., 2003; Simons, Garfield, & Murphy, 1984). Finally, the strong focus on disorder-
specific processes in CBT manualized therapy may not be optimally effective or efficient, given
that common features of emotional disorders account for more variance than disorder-specific
characteristics (Barlow, Allen, & Choate, 2004).
In response to these problems, transdiagnostic approaches to treatment have been attract-
ing greater attention. A unified treatment approach emphasizing commonalities across disor-
ders is not new to clinical psychology. However, the current context of this renewed interest in a
unified treatment perspective may offer fresh insight given that it follows many years of cogni-
tive research and treatment on various disorders. As an emerging debate within this disorder-
specific paradigm, it is possible that the transdiagnostic view could offer a new approach for the
thorny issues confronting CBT. The intent of this special issue is to examine the transdiagnostic
perspective, to discuss its potential contributions, and to identify its major shortcomings and
challenges.
In this concluding article we briefly summarize key issues delineated in the previous articles.
We begin by examining how transdiagnostic approaches have been defined and developed, fol-
lowed by a discussion of promising developments. We then discuss major limitations and chal-
lenges for transdiagnostic treatment research. We conclude by proposing a way forward so that
the transdiagnostic perspective can indeed be “new wine” for contemporary CBT rather than an
old approach cloaked in new rhetoric.

APPROACHES FOR DEFINING AND DEVELOPING

TRANSDIAGNOSTIC CBT
The contributors in this special issue are fairly consistent in their definitions of transdiagnostic
CBT. McEvoy, Nathan, and Norton (2008), for example, define transdiagnostic treatments as
“those that apply to the same underlying treatment principles across mental disorders, without
tailoring the protocol to specific diagnoses” (pp. 3–4). Mansell, Harvey, Watkins, and Shafran
(2008) define transdiagnostic treatment as “a therapy that is made available to individuals with
a wide range of diagnosis, and that does not rely on knowledge of these diagnoses to operate
effectively” (p. 14).
The contributors differ in how they develop their transdiagnostic interventions. Two main
approaches are evident. One is pragmatic, as illustrated by the work of Erickson, Janeck, and Tall-
man (2008). Here, transdiagnostic protocols are developed largely on the basis of clinical experi-
ence with interventions applicable to a range of disorders (e.g., relaxation training can be applied
62 Clark and Taylor

to many different disorders). The other approach is largely theory-driven. Here, transdiagnostic
protocols are developed to target cognitive and behavioral processes thought to be involved in
a wide range of psychological disorders (e.g., Mansell et al., 2008; for an extended discussion of
such processes see Harvey, Watkins, Mansell, & Shafran, 2004).
Regardless of whether one adopts a pragmatic or theory-driven approach, distinguishing
transdiagnostic from disorder-specific treatments in treatment outcome research may prove
to be difficult. To illustrate, some transdiagnostic protocols include individual consultation
sessions and disorder-specific interventions (e.g., Erickson et al., 2008). So, there are elements
of disorder-specific treatments in transdiagnostic protocols. Conversely, disorder-specific
protocols commonly contain transdiagnostic interventions. Therapeutic strategies such as self-
monitoring negative thoughts, cognitive restructuring, empirical hypothesis-testing exercises,
alternative explanations, graded exposure, acceptance of negative thought and emotion, and
behavioral activation are foundational for CBT of anxiety and depression. Indeed, early in the
development of cognitive therapy, Beck (1976) recognized that his cognitive conceptualization
and treatment for depression could be applied to anxiety disorders.
All of this suggests that the difference between transdiagnostic and disorder-specific
protocols is a matter of degree. Both transdiagnostic and disorder-specific protocols contain
transdiagnostic and disorder-specific interventions, although transdiagnostic protocols place
comparatively greater emphasis on interventions applicable to many different disorders. With
such subtle distinctions between protocols, treatment outcome studies may require large sample
sizes to be sufficiently powerful to detect efficacy differences. Nevertheless, we believe there is an
advantage to adopting a transdiagnostic approach, especially one with the flexibility to incorpo-
rate disorder-specific interventions.

THE PROMISE OF TRANSDIAGNOSTIC CBT

Despite the challenges for research on transdiagnostic CBT, there is good reason to remain hope-
ful about the potential contribution of this approach. The authors of this special issue observed
that there are strong arguments for developing and implementing transdiagnostic CBT for
anxiety and mood disorders. The psychopathological features these disorders have in common
account for more variance than their specific features, and this commonality has been found in
every domain of psychopathology, including genetic, biological, personality, social, emotional,
behavioral, and cognitive domains (Harvey et al., 2004; McEvoy et al., 2008). The list of shared
variables in these articles is extensive and probably will continue to expand. Variables include
negative affectivity (neuroticism), perceived uncontrollability and unpredictability, self-focused
attention, thought suppression, negative repetitive thought (e.g., worry, rumination), behavioral
inhibition/avoidance, safety-seeking, experiential avoidance, maladaptive metacognitive beliefs,
negative cognitive content, intolerance of negative emotion, unresolved conflicts over control,
and maladaptive coping responses. Many specific cognitive constructs that feature prominently
in contemporary cognitive-clinical theories and research are common factors (e.g., selective
attention, explicit memory bias, interpretational bias, emotional reasoning) (Mansell et al.,
2008). The disorder-specific theories appear to differ primarily in content rather than in process.
For example, selective attention to threat cues is a common feature of all anxiety disorders, but
the type of threat attended to may differ across disorders (e.g., a person with spider phobia may
selectively attend to spider-related stimuli, whereas a person with combat-related posttraumatic
stress disorder may attend primarily to combat-related cues).
Each of the articles in this special issue raises important practical reasons for exploring
the utility of transdiagnostic CBT. It was suggested that transdiagnostic CBT may be a more
efficient way to deal with patients having multiple clinical problems (Mansell et al., 2008). In
transdiagnostic treatment the clinician would not have to struggle to determine which disorder
 Transdiagnostic Perspective on Cognitive-Behavioral Therapy 63

is the principal diagnosis, which is an issue when one chooses which disorder-specific protocol to
implement. Group transdiagnostic CBT is also better suited to clinical settings where it is not fea-
sible to run diagnostically homogeneous groups (Erickson et al., 2008). It can also help address
the high cost and impracticality of training enough therapists to offer multiple, disorder-specific
treatments in a competent fashion, which may be a barrier for the dissemination of empirically
supported treatments. Erickson et al. (2008), for example, noted that their transdiagnostic pro-
tocol could be more easily learned by generalist clinicians or mental health professionals that
lack exposure to disorder-specific protocols. Thus, transdiagnostic CBT promises to overcome
the practical barriers in training and disseminating evidence-based treatment. Transdiagnostic
CBT also holds promise for disorder prevention and relapse prevention (Dozois, Seeds, & Collins,
2008; McEvoy et al., 2008).

IMPORTANT DIRECTIONS FOR FUTURE RESEARCH

Currently, the most pressing need is for treatment research on the comparative efficacy of transdi-
agnostic interventions and disorder-specific protocols and to determine whether transdiagnostic
therapies are superior to credible placebos. It is also necessary to determine how transdiagnostic
CBT performs when compared to disorder-specific CBT on a host of other variables, including
patient satisfaction, magnitude and durability of effects, and generalizability of treatment effects
to nontargeted clinical problems. Disorder-specific CBT has been shown to reduce disorders that
have not been directly targeted. For example, CBT for panic disorder and CBT for posttraumatic
stress disorder both reduce comorbid depression (Taylor, 2000, 2006). This raises the question
of whether transdiagnostic CBT is really necessary; is it sufficient to treat, in most cases, the
person’s most severe presenting problem? Transdiagnostic treatment would be contraindicated
if it fell substantially below the effectiveness of disorder-specific treatments, especially because
we know that disorder-specific treatment has broad clinical effects. Accordingly, it is important
to establish the clinical effectiveness of transdiagnostic treatments vis-à-vis disorder-specific
treatments.
Studies also need to determine which patients are best suited for transdiagnostic CBT. Erick-
son et al. (2008) believe that their transdiagnostic treatment is not well-suited for people with
posttraumatic stress disorder, obsessive-compulsive disorder, and people with more than two
comorbid disorders. Further research is needed to evaluate these clinical impressions and, more
generally, to determine whether other disorders or other variables (e.g., patient characteristics)
are contraindications for transdiagnostic treatment. In addition, research on mediators of trans-
diagnostic treatment efficacy is needed to determine whether the interventions really do target
the common features of anxiety and depression (Mansell et al., 2008; McEvoy et al., 2008).

TRANSDIAGNOSTIC CBT: A PROPOSAL

Progress on the development of transdiagnostic CBT for emotional disorders could follow a
pragmatic path in which clinical observation and trial-and-error are used to develop an opti-
mal protocol. This is a time-honored approach; many important advances in medicine have
been made on the basis of serendipity combined with astute observation (Meyers, 2007). Alter-
natively, a theory-based approach could be used in which the accumulating body of research
on transdiagnostic etiologic factors is used to devise a treatment protocol. Both approaches
have their merits and both have led to effective interventions, as illustrated in this special issue.
These approaches are not mutually exclusive; investigators could use a blend of theory and
clinical experience to improve transdiagnostic protocols. Nevertheless, we believe it is vital to
draw on transdiagnostic theory and research to develop optimal protocols.
64 Clark and Taylor

Mansell et al. (2008), building on their earlier work (Harvey et al., 2004), provide a good
starting point in this regard by identifying common cognitive constructs. The next step is to
identify functional relations among these constructs. This would need to be specified through
psychopathologic model development. Beck’s cognitive model of depression (Beck, 1987; Clark,
Beck, & Alford, 1999) and his cognitive model of anxiety (Beck, Emery, & Greenberg, 1985;
Clark & Beck, 2009) are examples of model building that have led to disorder-specific interven-
tions. Although these models have not explicitly articulated the common and specific features
of emotional disorders, there is no reason why transdiagnostic researchers could not build a
hierarchical model of anxiety and depression that explicitly includes common and specific
features.
The tripartite model of anxiety and depression (Clark & Watson, 1991; Watson, 2005) pro-
vides another possible starting point, but it lacks the precision required to forge a truly cognitive-
behavioral approach that embraces a transdiagnostic perspective. That is, the tripartite model
does not adequately specify the cognitive, behavioral, and other mechanisms involved in anxiety
and depression. A model of psychopathology is needed that incorporates all of the common and
specific constructs identified so far (e.g., self-absorption, repetitive negative thought, experiential
avoidance, thought suppression). Such a model would need to clearly specify the functional rela-
tions among constructs and how they contribute to the pathogenesis of anxiety and depression. As
Mansell et al. (2008) noted, any transdiagnostic model would also have to explain the emergence
of specificity; that is, why individuals develop one disorder rather than some other (e.g., panic
disorder rather than social anxiety disorder).
The next logical step after specification of a cognitive-behavioral transdiagnostic model of
emotional disorders is development of measures to assess the key common and specific processes
articulated in the model. Assessment should include construct-specific self-report questionnaires
as well as experimental protocols for measuring changes in particular constructs in real time.
For example, priming procedures could be developed to activate a construct like self-focused
attention (e.g., patients engage in a simulated social interaction while being videotaped). These
procedures could be introduced before and after transdiagnostic CBT to determine if treatment
led to a reduction in self-focused attention under relevant experimental conditions.
A further step in development would be the refinement of a transdiagnostic treatment
protocol. Intervention strategies known to have a significant impact on the common features of
anxiety and depression would be selected. Interventions that impact more than one shared ele-
ment (e.g., cognitive restructuring) might be given greater emphasis in the treatment protocol
than strategies that focus on a single unified construct (e.g., thought satiation). Some consid-
eration would have to be given to the amount of individual consultation and intervention for
disorder-specific variables incorporated into the treatment. A transdiagnostic treatment manual
should be written, therapist training protocol established, and minimum competency standards
articulated to ensure treatment integrity. Only after these advances would clinical researchers be
in a position to conduct the outcome and process studies needed to address the fundamental
questions we have raised about transdiagnostic CBT efficacy.
We do not see transdiagnostic protocols replacing disorder-specific CBT. Transdiagnostic
CBT should be viewed as complementary to well-established manualized disorder-specific CBT.
It may be that individuals could be offered a set number of group transdiagnostic sessions that
run concurrent with individual disorder-specific therapy sessions to improve generalizability,
reduce relapse, and deal with comorbid conditions. Transdiagnostic CBT might be introduced
prior to disorder-specific therapy to provide patients with generic skills for dealing with common
clinical problems. That might bolster patient motivation and acceptance of more demanding
individual disorder-specific therapy that would follow introductory transdiagnostic sessions.
Although rooted in a long historical tradition in psychotherapy, current interest in transdiagnos-
tic treatment represents a significant refocusing of CBT. Whether the promises of transdiagnostic
 Transdiagnostic Perspective on Cognitive-Behavioral Therapy 65

treatment can be fulfilled depends on the results of a systematic, theoretically driven psycho-
therapy research program.

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Correspondence regarding this article should be directed to David A. Clark, PhD, Department of Psychology,
University of New Brunswick, PO Box 4400, Fredericton, New Brunswick, Canada, E3B 5A3. E-mail: clark@
unb.ca