Positive cognitive behavior therapy in the treatment of depression: A randomized order within-subject comparison with traditional cognitive behavior therapy
Introduction
Cognitive behavior therapy (CBT) is the most well-researched evidence-based psychotherapeutic treatment for major depressive disorder (MDD). CBT is a structured, time-limited, and problem-focused form of psychotherapy for major depressive disorder targeting disorder-maintaining behavior as well as cognitions. Response and remission rates are around 60% and 30%, respectively, which is superior to waitlist or placebo conditions and comparable to rates of other evidence-based psychotherapies and antidepressant medication (Cuijpers et al., 2013). Moreover, CBT may have favorable long-term effects regarding rates of relapse in comparison to treatment with anti-depressant medication (Bockting, Hollon, Jarrett, Kuyken, & Dobson, 2015; Zhang, Zhang, Zhang, Jin, & Zheng, 2018). However, these findings indicate that there is ample room for improvement of efficacy. One of the ways to increase efficacy of CBT is a more explicit and systematic focus on positive emotions and positive mental health. The following three arguments outline why this may have the potential to improve CBT.
First, CBT for MDD is aimed mainly at clinical response or remission. From a patient perspective, achieving a maximum decrease of depressive symptomatology entails a too narrow definition of successful treatment (Demyttenaere et al., 2015; Zimmerman et al., 2012, 2013). The reduction or absence of depressive symptoms does not automatically translate into increased well-being (Keyes, 2002). It leaves an increase in positive mental health, characterized by features such as optimism, a general sense of well-being, and a return to usual or even better than premorbid levels of functioning, unaddressed (Zimmerman et al., 2006). Broadening the focus of CBT for MDD by including themes such as optimism, strengths, meaning and life-goals may therefore do more justice to patient expectations, as well as make patients’ lives more fulfilled and resilient.
Second, within the traditional framework of CBT there is a relative neglect of the experience and enhancement of positive emotions, which is typically decreased in depressed subjects (Watson & Naragon-Gainey, 2010). An increase in positive emotions has repeatedly been shown to be more important than a decrease in negative emotions when it comes to well-being, and the prevention of, and recovery from depression (Geschwind et al., 2011, 2010; Höhn et al., 2013; Khazanov & Ruscio, 2016). Accordingly, recent reviews concluded that, in addition to the reduction of negative emotions, the promotion of positive emotions should be a main focus in the treatment of depression (Craske, Meuret, Ritz, Treanor, & Dour, 2016; Dunn, 2012).
Third, even healthy people pay more attention to negative events than positive events (a phenomenon known as negativity bias) (Baumeister et al., 2001). In people with depression such a bias is even more prominent (Gotlib, Krasnoperova, Yue, & Joormann, 2004; Kircanski & Gotlib, 2015; Koster, De Raedt, Leyman, & De Lissnyder, 2010). CBT may inadvertently reinforce an already present negativity bias by asking patients to register weaknesses and problematic instances and by elaborating on this during and outside the sessions.
Two strategies may be used simultaneously to enhance a more explicit and systematic focus on positive emotions and positive mental health within a CBT framework. A first strategy is to change the content of CBT through integration with solution-focused brief therapy, such that the content of therapy is aimed at structurally and persistently reinforcing attention to positive features, both during sessions as well as in homework exercises (Bannink, 2012, 2017; Padesky & Mooney, 2012; De Shazer, Dolan, Konnan, & Berg, 2012). A second strategy is to address themes such as optimism and well-being explicitly during treatment, for example through integrating traditional CBT protocols with positive psychology interventions (Johnson & Wood, 2017). We will now describe both strategies in more detail.
Solution-focused brief therapy focuses on the preferred future of the patient and identifies what works for a patient. Therapist and patient and are co-experts (Bannink, 2012; De Shazer et al., 2012). Solution-focused brief therapy is characterized by orientation towards positive features and successes, by stimulating patients to elaborate on behavior and cognitions during better moments (looking at exceptions to problems rather than looking at problems), and by encouraging transfer of successful strategies in problematic situations. Evidence from more fundamental research on neural networks and habit formation suggests that persistent reinforcement of orientation to positive features, rather than negative or neutral features, might stimulate the development of alternative, positive information processing habits more optimally (Berkman, 2018; Eguchi et al., 2017; Verplanken, 2010; Wood & Neal, 2007). Shifting attention towards the positive in CBT may thus be an underused aid when it comes to stimulating positive emotions as well as challenging the pervasive negativity biases which characterize MDD.
Regarding integration with positive psychology, to date, evidence suggests that positive psychology interventions have modest effects on well-being and depressive symptomatology. Earlier meta-analyses (Bolier et al., 2013; Sin & Lyubomirsky, 2009), based on studies in predominantly non-clinical populations, showed small significant effect sizes of positive psychology interventions on well-being (r = 0.29, d = 0.20) and depressive symptoms (r = 0.31, d = 0.23). A recent meta-analysis in clinical samples (Chakhssi, Kraiss, Sommers-Spijkerman, & Bohlmeijer, 2018) again reported small but significant effect sizes for well-being (g = 0.28) and depression (g = 0.27). However, after removal of low-quality studies these effect sizes decreased to a significant effect size (g = 0.19) for well-being, but a non-significant effect size for depression (g = 0.07). Given that many studies suffered from shortcomings in allocation procedures, assessment outcome, drop-out description, insufficient power, and an absence of intention-to-treat analysis, the authors classified the quality of included studies as low to medium, and called for improvement of research methodology of PPIs for psychiatric disorders (Chakhssi et al., 2018). Taken together, these meta-analyses thus suggest that integrating CBT with positive psychology exercises may be useful.
Some may think of Fava's well-being therapy (Fava & Tomba, 2009) at this point, because it integrates traditional CBT elements with findings and interventions from positive psychology. However, well-being therapy was originally designed as a treatment for residual symptoms after the primary diagnosis has been addressed (i.e., not as an acute treatment; Fava, Cosci, Guidi, & Tomba, 2017). Moreover, well-being therapy largely focuses on analyzing and repairing problems, with the goal of removing cognitive and behavioral obstacles to well-being (rather than building well-being bottom-up; Bannink & Jansen, 2017; Fava et al., 2017). For example, in the intermediate sessions of well-being therapy, therapist and client focus on monitoring and identifying thoughts, beliefs and behaviors that lead to premature interruption of well-being (Fava, 2016; Fava & Tomba, 2009). Well-being therapy therefore does not use the strategy of structural and persistent reinforcement attention to positive features in therapy sessions and homework. Recently, Bannink introduced positive CBT (P-CBT; Bannink, 2012, 2017). By blending CBT with (i) a persistent focus on positive features, as well as (ii) positive psychology interventions (see section ‘intervention’), P-CBT uses both strategies to create a strong focus on positive emotions and positive mental health.
Against this background of previous work, the aim of our study was to examine the efficacy of positive CBT as an alternative to traditional CBT (T-CBT) for the treatment of MDD, and to compare both forms of CBT with regard to their short-term effects on depressive symptoms and positive mental health. We aimed at recruiting actively help-seeking patients who had been referred to an outpatient treatment facility specialized in depressive disorders and thus had moderate to severe, rather than subthreshold or mild, complaints. Because willingness to participate in clinical research is low for these populations in routine health care settings in the Netherlands, we opted for a crossover within-subjects design in order to make most efficient use of this limited resource. A within-subject design significantly reduces noise and hence the number of participants needed in terms of power but comes with the risk of carry-over or order effects. Within treatments, we alternated P-CBT and T-CBT in two blocks of 8 sessions each (with the order of blocks counterbalanced and randomized). We investigated whether improvement of depressive symptoms and negative affect differs between P-CBT and T-CBT, and whether P-CBT would be accompanied by greater improvements in positive affect and other indices of positive mental health (optimism, subjective happiness), compared to T-CBT. Lastly, given the necessity of checking for possible qualifying effects inherent to our crossover design, we explored which order of application of T-CBT and P-CBT would be optimal if one were to use P-CBT as an add-on to T-CBT (even though P-CBT has originally been conceptualized as a stand-alone alternative to T-CBT; Bannink, 2012, 2017).
Section snippets
Design
In a within-subject experimental crossover design, T-CBT was alternated with P-CBT in two blocks of eight sessions each (with the order of blocks counterbalanced and randomized for men and women separately). Immediately after each session, participants completed the 16-item Quick Inventory of Depressive Symptoms, which was the main outcome measure (QIDS; Trivedi et al., 2004). At baseline and after every four sessions, participants additionally completed a battery of more extensive
Sample characteristics
Baseline demographic and characteristics are shown in Table 1. Sixty-one percent of participants were female, 79% were low-educated, and 35% were either unemployed or received benefits from social security. All were diagnosed with MDD, and 37% had one or more additional psychiatric diagnoses. Participants reported feeling that they needed help for their current complaints since 11 months on average, indicating that their complaints were not short-lived. By chance, significantly more individuals
Discussion
We examined whether positive CBT (P-CBT; Bannink, 2012, 2017) represented an improvement for the treatment of MDD, compared to traditional CBT (T-CBT), at least in the short-term effects. In a randomized-order within–subject comparison, these two treatment strategies were alternated in two blocks of eight sessions in clinically depressed individuals. We tested whether improvement of depressive symptoms and negative affect differed in P-CBT compared to T-CBT, and whether P-CBT would be
Declaration of interests
Fredrike Bannink receives royalties for publications on positive CBT, and payment for teaching positive CBT workshops.
Role of funding source
All costs were covered by Maastricht University. The authors received no funding from an external source.
Acknowledgements
We thank our therapists Patrick Fokkema, Cristel Achterberg, and Nienke Jabben for their invaluable contribution to our study. We are grateful to the members of the Virenze Riagg mood disorder team for supporting execution of the study and for screening all incoming participants. Finally, we would like to thank the data management team, in particular Nina Aussems, for their help with data collection.
References (70)
- et al.
Intelligence and educational achievement
Intelligence
(2007) - et al.
What is important in being cured from depression? Discordance between physicians and patients (1)
Journal of Affective Disorders
(2015) - et al.
Early improvement in positive rather than negative emotion predicts remission from depression after pharmacotherapy
European Neuropsychopharmacology
(2011) - et al.
Mood-congruent attention and memory bias in dysphoria: Exploring the coherence among information-processing biases
Behaviour Research and Therapy
(2010) - et al.
Changes in affect during treatment for depression and anxiety
Behaviour Research and Therapy
(2007) - et al.
Become more optimistic by imagining a best possible self: Effects of a two week intervention
Journal of Behavior Therapy and Experimental Psychiatry
(2011) - et al.
The 16-item Quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in patients with chronic major depression
Biological Psychiatry
(2003) - et al.
On the specificity of positive emotional dysfunction in psychopathology: Evidence from the mood and anxiety disorders and schizophrenia/schizotypy
Clinical Psychology Review
(2010) - et al.
The effect of CBT and its modifications for relapse prevention in major depressive disorder: A systematic review and meta-analysis
BMC Psychiatry
(2018) - et al.
A new type of scale for determining remission from depression: The remission from depression questionnaire
Journal of Psychiatric Research
(2013)
Practicing positive CBT: From reducing distress to building success
Positive CBT in practice
Positieve gezondheidszorg. [Positive health care]
No pain, no gain: Depressed clients' experiences of cognitive behavioural therapy
British Journal of Clinical Psychology
Bad is stronger than good
Review of General Psychology
Cognitive therapy of depression
The neuroscience of goals and behavior change
Consulting Psychology Journal: Practice and Research
A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence
Clinical Psychology Review
Protocollaire behandeling van patiënten met een depressieve stoornis. [Protocol-based treatment of patients with major depressive disorder]
Positive psychology interventions: A meta-analysis of randomized controlled studies
BMC Public Health
The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: A systematic review and meta-analysis
BMC Psychiatry
Treatment for anhedonia: A neuroscience driven approach
Depression and Anxiety
A convenient method of obtaining percentile norms and accompanying interval estimates for self-report mood scales (DASS, DASS-21, HADS, PANAS, and SAD)
British Journal of Clinical Psychology
The positive and negative affect schedule (PANAS): Construct validity, measurement properties and normative data in a large non-clinical sample
British Journal of Clinical Psychology
The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons
World Psychiatry
More than miracles: The state of the art of solution- focused brief therapy
Helping depressed clients reconnect to positive emotion experience: Current insights and future directions
Clinical Psychology & Psychotherapy
Understanding the neural basis of cognitive bias modification as a clinical treatment for depression
Journal of Cons
Statistical power analyses using G*power 3.1: Tests for correlation and regression analyses
Behavior Research Methods
Well-being therapy
Well-being therapy in depression: New insights into the role of psychological well-being in the clinical process
Depression and Anxiety
Increasing psychological well-being and resilience by psychotherapeutic methods
Journal of Personality
The undoing effect of positive emotions
Motivation and Emotion
De snijders-oomen niet-verbale intelligentietest: Bruikbaar bij ouderen? [The snijders-oomen nonverbal intelligence test: Feasible for the elderly?]
Tijdschrift voor Gerontologie en Geriatrie
Cited by (49)
The effectiveness and equivalence of different versions of a brief online Best Possible Self (BPS) manipulation to temporary increase optimism and affect
2023, Journal of Behavior Therapy and Experimental PsychiatryChanges in positive and negative affect following prolonged exposure for PTSD comorbid with alcohol use disorder: Secondary analysis of a randomized clinical trial
2022, Behaviour Research and TherapyCitation Excerpt :The literature, however, remains nascent and even less is known about how well non-pharmacological treatments change PA levels in PTSD. In individuals with depression and anxiety, emerging psychotherapeutic treatments that explicitly focus on the upregulation of PA (Craske et al., 2019; C. T. Taylor et al., 2017; Dunn et al., 2020; Geschwind et al., 2019) are premised on the mechanisms underpinning diminished PA (e.g., blunted reward sensitivity, attentional biases away from positive information) and provide initial support for targeting PA to improve outcomes. In sum and notwithstanding limitations, the current findings provide novel insights into the restoration of PA and NA after the administration of two established treatments for PTSD and AUD.