Positive cognitive behavior therapy in the treatment of depression: A randomized order within-subject comparison with traditional cognitive behavior therapy

https://doi.org/10.1016/j.brat.2019.03.005Get rights and content

Highlights

  • Positive CBT (P-CBT) has a solution focus and uses positive psychology exercises.

  • P-CBT resulted in stronger reduction of depression during 2nd phase of treatment.

  • P-CBT was associated with more clinically significant change than traditional CBT.

  • Dropout was significantly lower when starting with positive (cf. traditional) CBT.

  • The relative impact of solution focus and positive psychology is still unclear.

Abstract

Previous research suggests that a stronger focus on positive emotions and positive mental health may improve efficacy of Cognitive Behavior Therapy (CBT). Objectives were to compare differential improvement of depressive symptoms (primary outcome), positive affect, and positive mental health indices during positive CBT (P-CBT; CBT in a solution-focused framework, amplified with optional positive psychology exercises) versus traditional, problem-focused CBT (T-CBT). Forty-nine patients with major depressive disorder (recruited in an outpatient mental health care facility specialized in mood disorders) received two treatment blocks of eight sessions each (cross-over design, order randomized). Intention-To-Treat mixed regression modelling indicated that depressive symptoms improved similarly during the first, but significantly more in P-CBT compared to T-CBT during the second treatment block. Rate of improvement on the less-frequently measured secondary outcomes was not significantly different. However, P-CBT was associated with significantly higher rates of clinically significant or reliable change for depression, negative affect, and happiness. Effect sizes for the combined treatment were large (pre-post Cohen's d = 2.71 for participants ending with P-CBT, and 1.85 for participants ending with T-CBT). Positive affect, optimism, subjective happiness and mental health reached normative population averages after treatment. Overall, findings suggest that explicitly focusing on positive emotions efficiently counters depressive symptoms.

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)

  • F.P. Bannink

    Practicing positive CBT: From reducing distress to building success

    (2012)
  • F.P. Bannink

    Positive CBT in practice

  • F.P. Bannink et al.

    Positieve gezondheidszorg. [Positive health care]

    (2017)
  • M. Barnes et al.

    No pain, no gain: Depressed clients' experiences of cognitive behavioural therapy

    British Journal of Clinical Psychology

    (2013)
  • R.F. Baumeister et al.

    Bad is stronger than good

    Review of General Psychology

    (2001)
  • A.T. Beck et al.

    Cognitive therapy of depression

    (1979)
  • E.T. Berkman

    The neuroscience of goals and behavior change

    Consulting Psychology Journal: Practice and Research

    (2018)
  • C. Bockting et al.

    A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence

    Clinical Psychology Review

    (2015)
  • C. Bockting et al.

    Protocollaire behandeling van patiënten met een depressieve stoornis. [Protocol-based treatment of patients with major depressive disorder]

  • L. Bolier et al.

    Positive psychology interventions: A meta-analysis of randomized controlled studies

    BMC Public Health

    (2013)
  • F. Chakhssi et al.

    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

    (2018)
  • M.G. Craske et al.

    Treatment for anhedonia: A neuroscience driven approach

    Depression and Anxiety

    (2016)
  • J.R. Crawford et al.

    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

    (2009)
  • J.R. Crawford et al.

    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

    (2004)
  • P. Cuijpers et al.

    The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons

    World Psychiatry

    (2013)
  • S. De Shazer et al.

    More than miracles: The state of the art of solution- focused brief therapy

    (2012)
  • B.D. Dunn

    Helping depressed clients reconnect to positive emotion experience: Current insights and future directions

    Clinical Psychology & Psychotherapy

    (2012)
  • A. Eguchi et al.

    Understanding the neural basis of cognitive bias modification as a clinical treatment for depression

    Journal of Cons

    (2017)
  • F. Faul et al.

    Statistical power analyses using G*power 3.1: Tests for correlation and regression analyses

    Behavior Research Methods

    (2009)
  • G.A. Fava

    Well-being therapy

    (2016)
  • G.A. Fava et al.

    Well-being therapy in depression: New insights into the role of psychological well-being in the clinical process

    Depression and Anxiety

    (2017)
  • G.A. Fava et al.

    Increasing psychological well-being and resilience by psychotherapeutic methods

    Journal of Personality

    (2009)
  • B.L. Fredrickson et al.

    The undoing effect of positive emotions

    Motivation and Emotion

    (2000)
  • M. Gerritsen et al.

    De snijders-oomen niet-verbale intelligentietest: Bruikbaar bij ouderen? [The snijders-oomen nonverbal intelligence test: Feasible for the elderly?]

    Tijdschrift voor Gerontologie en Geriatrie

    (2001)
  • Geschwind, N., Bosgraaf, E., Bannink, F., & Peeters, F. (n.d.). Now I can build the life that I want. The added value...
  • Cited by (49)

    • Changes 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 Therapy
      Citation 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.

    View all citing articles on Scopus
    View full text