New Psychotherapies That Focus on Positive Experiences Could Better Treat Depression and Anxiety

Katie, a 40-year-old woman in the county of Devon in England, has battled depression most of her life. She’s received lots of treatment, including with cognitive-behavioral therapy (CBT). The latter approach did help, she says. “I am prone to catastrophizing, and CBT helped me reduce those fears and some self-harming behaviors,” Katie adds, “But I never felt joy.”

CBT is the gold standard therapy for treating depression and anxiety, one or both of which will afflict around 20 percent of people during their lifetime. It may be the best remedy we have, a growing number of scientists say, but it doesn’t help everyone. Research shows that only half of patients benefit and that only half of those who do benefit do so long-term. CBT does reduce symptoms such as low mood and fearfulness. For many, however, it doesn’t restore positive feelings such as happiness or excitement.

“We had always assumed that by reducing negative emotions—anger, fear, anxiety, sadness—the natural consequence would be for positive emotions to rise on their own,” says clinical psychologist Michelle Craske of the University of California, Los Angeles. “And they don’t—well, not reliably.”

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Feeling the pressing need to do better, Craske and other scientists are developing new treatments to fill this gap. They are using elements of CBT but turning it on its head. Instead of working to reduce patients’ unrealistic worries or self-defeating beliefs, the researchers focus on helping them identify and enlarge their positive emotions, no matter how transient or tiny. These new approaches are now being tested in large-scale clinical trials in the U.S. and the U.K. and are showing great promise.

One of the largest efforts underway involves a technique called positive affect treatment (PAT),which was developed by Craske, clinical psychologist Alicia Meuret of Southern Methodist University and their colleagues. The researchers are now conducting their third National Institute of Health–funded clinical trial of PAT. In the two trials published so far, they compare the results of 15 weeks of PAT against the same time frame for a version of CBT, which they call negative affect treatment (NAT). The participants, who have been randomly assigned to a treatment, have all been diagnosed with depression and/or anxiety. Most have also suffered from anhedonia, a reduced ability to feel positive emotions.

Craske’s team based PAT on decades of research that has showed that people with limited ability to feel pleasurable emotions were likelier to develop anxiety or depression. Brain research revealed that people whose neural circuits did not show activation in the region that registers “reward” correlated with those who experienced depression and anxiety.

Craske and her colleagues hypothesized that targeting this mechanism for reward sensitivity could help strengthen affected people’s ability to feel positive emotions. Getting the mind and brain to process rewards consists of three parts: anticipation, consumption and learning—or, in plainer English, wanting, enjoying and learning.

Imagine a teenage girl who hears Taylor Swift is coming to town and offers to clean the house for a month if her parents will buy tickets. That’s wanting. At the concert she’s euphoric. That’s enjoyment. She notices the cheaper seats are almost as good, and that might make it easier to go next time. That’s learning.

Someone with depression and anxiety may fall short on any or all of these measures. For instance, let’s say a woman with these conditions tells her therapist that she used to love lunching with a friend, but lately, even when she was able to make herself go, she felt numb when there and worse afterward. The therapist then assigns this patient to schedule a lunch date, and she does so but feels down afterward. Her friend had to leave early, and she’s sure that she was boring, that her friend won’t want to see her again, and that she’ll end up friendless and alone.

In typical CBT, the therapist would help this woman assess her beliefs and show her they’re faulty. The therapist would also examine her catastrophic fears and scale them down to realistic and manageable size. If the patient hyperventilated, she might be taught breathing techniques to gain calm.

In PAT, the therapist would ask this patient to identify anything enjoyable about her lunch date, however tiny. Let’s say that the patient offers that the fragrances from the kitchen made her hungry, that her friend laughed at an anecdote she told and that, at the end, her friend gave her a hug. The therapist then asks her to savor those “silver linings,” to stay with them in all their sensory and emotional dimensions—the scents, her friend’s laugh, the warmth of the hug—and to imagine having these experiences in the future. PAT also incorporates elements such as practicing gratitude and generosity. Trial results showed that PAT was significantly more effective than NAT for those with anhedonia, moderate to severe depression and anxiety.

Another therapy called augmented depression therapy (ADepT) overlaps with PAT, says clinical psychologist Barney Dunn of the University of Exeter in England, who developed the treatment with his colleagues. It includes identifying and savoring positive experiences. But it goes further. “ADepT focuses on both positive and negative affect in a pragmatic, solution-focused way,” Dunn says.For example, it helps patients identify and change patterns of thought and behavior that interfere with achieving their goals in life. If someone who was about to give a talk felt like an imposter, he says, CBT would test the validity of that feeling. “ADepT,” he says, “would instead ask what thought might be useful and try this on for size: ‘I know enough about this topic and will do an okay job.’”

In the first clinical trial for ADepT, it was more effective than CBT at reducing symptoms of depression and anxiety and improving overall well-being, including by making people feel more pleasure and function better in life. Eighty percent of the ADepT participants showed reduced symptoms compared with 60 percent of the CBT group. Significantly, a year later, 60 percent of those who had improved with ADepT stayed well compared with 50 percent of those who had done so with CBT. “So we’re getting more people better, and they’re staying better for longer by choosing to turn toward the positive,” Dunn says.

A challenge to focusing patients on the positive is that many fear happiness. Some believe it is fleeting and will be followed by a terrible fall. Others feel they don’t deserve to be happy. “People with depression do a whole set of behaviors to snuff out the joy because it’s so weird and uncomfortable,” Dunn says. For that reason, he says, it’s necessary to help them accept happiness in very small steps. “If someone’s afraid of spiders, you don’t stick a tarantula in their face.”

Many anxiety sufferers believe that worrying prevents bad things from happening. They’re certain that expecting the worst protects them from one of their biggest fears: letting themselves feel happy and then being felled by the gut punch of a horrible event. Experts call this fear contrast avoidance. To circumvent it, anxious people apply killjoy thinking to any glimmer of glee.

One new tool to target contrast avoidance is an experimental phone counseling app called SkillJoy. Created by Skidmore College psychologist Lucas LaFreniere and Pennsylvania State University psychologist Michelle Newman, the app prompts users to notice and savor positive experiences throughout the day and, despite discomfort, to stay with the good feelings as long as possible. In a randomized clinical trial that compared the tool against an app that did not encourage savoring, SkillJoy significantly reduced contrast avoidance.

Other examples of such “positive therapies” are emerging: among them are amplification of positivity treatment, which was designed to improve social connectedness, and behavioral activation therapy, which has been used to treat anhedonia. Such positive-psychology-focused therapy may, some argue, eventually become the treatment of choice for a certain kind of patient, or it could become a key element in a hybrid therapy that will become the new gold standard. When these techniques are used in psychotherapy with private patients, Craske says, they will be adapted to the individual. A patient whose priority is getting rid of panic attacks should probably start with CBT, she says. A depressed patient who most wants to feel a sense of contentment and joy should probably go for a positive therapy.

Katie, the English woman who yearned to feel pleasure, is finding it with the help of an AdepT therapist. She’s been able to identify things she loves such as swimming in the ocean. Whether taking her regular dip along her local Devon coastline or reliving her vacation plunge into the frigid waters off Iceland, she experiences a joy that permeates her life and makes the hard things easier to handle. “Capturing these moments and building on them has been transformative,” she says. “I feel like I am starting to live for the first time.”