For decades, Cognitive Behavioural Therapy (CBT) has been considered the gold standard for treating depression and anxiety—conditions that will affect around one in five people during their lifetime. CBT has strong evidence behind it and, for many, it reduces distressing symptoms such as low mood, fear, and catastrophic thinking.
Yet there is a growing recognition within scientific circles that CBT does not work for everyone. Research shows that only about half of patients benefit, and only half of those experience lasting improvement. Crucially, while CBT often helps reduce negative emotions, it does not reliably restore positive ones—such as happiness, excitement, or a sense of aliveness.
Psychologists 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. But…they don’t.. not reliably.
This insight has prompted a quiet but profound shift in therapeutic thinking.
Turning Therapy on Its Head
Rather than focusing primarily on correcting distorted thoughts or dampening distress, researchers like Michelle Craske at the University of California, Los Angeles are exploring therapies that actively cultivate positive emotional states—even when those states are fleeting, subtle, or initially uncomfortable.
These approaches borrow tools from CBT but reorient the goal: not merely reducing suffering, butstrengthening the nervous system’s capacity for pleasure, connection, and reward. Large-scale clinical trials in the U.S. and U.K. suggest this shift may be especially powerful for people who experience anhedonia—the blunting or loss of positive emotion that often accompanies depression and anxiety.
One of the most researched of these approaches is Positive Affect Treatment (PAT), developed by Craske and Alicia Meuret of Southern Methodist University. PAT has now been tested in multiple National Institutes of Health–funded trials, comparing it with a CBT-style approach called Negative Affect Treatment (NAT).
Participants in these studies all lived with depression and/or anxiety, and many struggled to feel pleasure at all. Results showed that PAT was significantly more effective than NAT for people with moderate to severe symptoms and pronounced anhedonia.
Reawakening the Brain’s Reward System
PAT is grounded in decades of research showing that people who struggle to feel pleasure are more vulnerable to anxiety and depression. Brain imaging studies reveal that, in many of these individuals, neural circuits involved in reward processing are underactive.
Craske and her colleagues focused on strengthening this system through three key stages of reward:
- Anticipation (wanting)
- Consumption (enjoying)
- Learning (remembering and integrating)
In simple terms: learning to look forward to, fully experience, and mentally store positive moments.
Imagine a teenage girl who hears Taylor Swift is coming to town and eagerly offers to clean the house for a month if her parents buy tickets. That’s anticipation. At the concert, she feels euphoric—that’s enjoyment. Later, she realises the cheaper seats were still great, making future concerts feel more accessible. That’s learning.
For someone with depression or anxiety, any one of these steps may be blocked.
From Correcting Thoughts to Savoring Experience
Consider a woman who tells her therapist she used to love having lunch with a friend, but now feels numb during the meal and worse afterward. After a recent lunch, she spirals into self-criticism—convinced she was boring, that her friend left early because of her, and that she’ll eventually be alone.
In traditional CBT, therapy would focus on challenging these beliefs, examining evidence, and calming the body’s fear response.
In PAT, the therapist takes a different route.
The woman is gently asked to identify anything enjoyable about the lunch—however small. Perhaps the aroma of food made her hungry. Perhaps her friend laughed at a story. Perhaps there was a warm hug at the end. She is then guided to linger with these moments, sensing them fully and imagining their return.
This deliberate savouring—combined with practices such as gratitude and generosity—helps retrain the brain to register and retain positive experiences, much like energy healing practices that attune awareness to subtle but life-giving sensations.
Beyond Positivity: A Practical Balance
Another emerging approach, Augmented Depression Therapy (ADepT), overlaps with PAT but goes further. Developed by Barney Dunn at the University of Exeter in England, ADepT works pragmatically with both positive and negative emotions.
Rather than asking whether a thought is “true” (as CBT does), ADepT asks whether it is useful. If someone about to give a talk feels like an imposter, CBT might challenge the belief. ADepT might instead offer a stabilising alternative: “I know enough about this topic, and I will do an okay job.”
Clinical trials show that ADepT outperforms CBT not only in reducing symptoms, but in improving overall well-being. Eighty percent of participants improved, compared with sixty percent in CBT—and more importantly, they were more likely to stay well a year later.
This translates into: choosing to turn toward the positive helps get more people better, and helps them to stay better for longer.
Why Happiness Can Feel Unsafe
One challenge with positivity-focused therapies is that many people are deeply afraid of happiness. Some believe joy is fleeting and will be followed by disaster. Others feel undeserving. Many unconsciously suppress pleasure because it feels unfamiliar or unsafe. People with depression often employ a whole set of behaviours to snuff out the joy because it feels uncomfortable.
Anxiety adds another layer. Many anxious individuals believe that worrying protects them—that expecting the worst prevents emotional devastation. This phenomenon, known as contrast avoidance, causes people to dampen joy before it can fully arise.
To address this, researchers have developed tools like SkillJoy, an experimental phone app created by Lucas LaFreniere and Michelle Newman. The app encourages users to notice and remain with positive feelings—even when discomfort arises. Early trials show it significantly reduces contrast avoidance.
A New Gold Standard?
Other “positive therapies” are emerging, including amplification of positivity treatment (designed to improve social connection) and behavioural activation therapy, which has long been used to treat anhedonia.
Rather than replacing CBT, these approaches may become part of a hybrid future—one that recognises that some people need first to calm fear, while others long most deeply to feel joy, meaning, and vitality again.
As Craske notes, therapy should be tailored. Someone overwhelmed by panic may benefit most from CBT. Someone who feels empty, flat, or disconnected may need help turning gently toward pleasure. For patients, capturing these moments and building on them can be transformative.
As the year closes and a new one opens, perhaps healing is not only about releasing what hurts—but about learning, patiently and courageously, to let the good in.
REFERENCES
Craske, M. G. et al. (2023). Positive affect treatment targets reward sensitivity: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 91(6), 350–366. https://doi.org/10.1037/ccp0000805
Dunn, Barnaby D. et al. (2023) Preliminary clinical and cost effectiveness of augmented depression therapy versus cognitive behavioural therapy for the treatment of anhedonic depression (ADepT): a single-centre, open-label, parallel-group, pilot, randomised, controlled trial. eClinicalMedicine, Volume 61, 102084. DOI: 10.1016/j.eclinm.2023.102084
LaFreniere LS, Newman MG (2023). Reducing contrast avoidance in GAD by savoring positive emotions: Outcome and mediation in a randomized controlled trial. J Anxiety Disord. Jan;93:102659.doi: 10.1016/j.janxdis.2022.102659
Taylor, C. T. et al (2024). Amplification of Positivity Treatment for Anxiety and Depression: A Randomized Experimental Therapeutics Trial Targeting Social Reward Sensitivity to Enhance Social Connectedness. Biological Psychiatry,Volume 95, Issue 5, Pages 434-443. https://doi.org/10.1016/j.biopsych.2023.07.024
Cernasov, P. M. et al. (2024). A parallel-arm, randomized trial of Behavioral Activation Therapy for anhedonia versus mindfulness-based cognitive therapy for adults with anhedonia. Behaviour Research and Therapy, Volume 182, 104620. https://doi.org/10.1016/j.brat.2024.104620
Craske, M.G. et al. Positive affect and reward processing in the treatment of depression, anxiety and trauma. Nat Rev Psychol 3, 665–685 (2024). https://doi.org/10.1038/s44159-024-00355-4