Positive cognitive behavior therapy in the treatment of depression: A randomized order within-subject comparison with traditional cognitive behavior therapy
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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.
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Explicitly focusing on positive emotions efficiently improves depressive symptoms and helps to achieve more profound change in positive functioning measures.
“Recent findings suggest that explicitly focusing on positive emotions efficiently improves depressive symptoms and helps to achieve more profound change in positive functioning measures [98–100].”
From Protocol for a randomized controlled dismantling study of an internet-based intervention for depressive symptoms: Exploring the contribution of behavioral activation and positive psychotherapy strategies (2019) · cites this paper as [98]
The Abstract and Discussion report that positive CBT countered depressive symptoms, with greater improvement than traditional CBT in the second treatment block. They also report greater reliable change in subjective happiness and suggest a shift toward positive mental health, but improvement rates on the other positive-functioning measures did not differ significantly. Thus, the broader claim of more profound change across positive-functioning measures overstates the findings. (LLM, conf=0.82)
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When hope springs a leak: Aversion to positivity as a key to understanding depressed persons
Gallagher, M. R., Salem, T., & Winer, E. S. (2023) · Current Psychology · doi:10.1007/s12144-023-04917-2 · Cited by 11 · see citing works
“Positive CBT has shown promising initial evidence as a treatment modality (Geschwind et al., 2019, 2020).”
Peipert, A., Rodríguez‐Quintana, N., & Lorenzo‐Luaces, L. (2022) · International Journal of Cognitive Therapy · doi:10.1007/s41811-022-00131-3 · Cited by 12 · see citing works
Díez, G. G., Martin-Subero, I., Zangri, R. M., Kulis, M., Andreu, C. I., Blanco, I., Roca, P., Cuesta, P., García, C., Garzón, J., et al. (2023) · PLoS ONE · doi:10.1371/journal.pone.0283169 · Cited by 11 · see citing works
‘It just doesn't feel right’ and other reasons why some people fear and avoid positive emotions
Bogaert, L., Dunn, B. D., Walentynowicz, M., & Raes, F. (2023) · Acta Psychologica · doi:10.1016/j.actpsy.2023.103901 · Cited by 10 · see citing works
Mahmoodi, M., Farajkhoda, T., Nadjarzadeh, A., & Mahmoodabadi, H. Z. (2023) · Scientific Reports · doi:10.1038/s41598-023-43940-y · Cited by 10 · see citing works
Amirshahi, M., Saremi, A. A., Nouri, R., Karbalaee, M. H., & Sadat, R. H. (2024) · Journal of Education and Health Promotion · doi:10.4103/jehp.jehp_687_23 · Cited by 10 · see citing works
“[33] In explaining the results of the present study, it can be said that negative perceptions of body image in patients with PCOS are associated with dissatisfaction with appearance, decreased female identity, decreased feeling of sexual attractiveness, and self‑consciousness about appearance.”
ResultIncreases in positive emotions as precursors to therapeutic change
McNeil, G. D., & Repetti, R. L. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2698 · Cited by 10 · see citing works
Boselie, J. J. L. M., Vancleef, L. M. G., van Hooren, S., & Peters, M. L. (2023) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2023.101837 · Cited by 10 · see citing works
Mira, A., Díaz-García, A., Castilla, D., Campos, D., Romero, S., Bretón-López, J., García-Palacios, A., Baños, R., & Botella, C. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2099-2 · Cited by 9 · see citing works
Vara, M. D., Mira, A., Miragall, M., García-Palacios, A., Botella, C., Gili, M., Riera-Serra, P., García-Campayo, J., Mayoral-Cleries, F., & Baños, R. M. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17218094 · Cited by 7 · see citing works
Schürmann‐Vengels, J., Kneuer, A., Cavus, Ö., & Flückiger, C. (2025) · Behaviour Research and Therapy · doi:10.1016/j.brat.2025.104789 · Cited by 7 · see citing works
Vittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103996 · Cited by 6 · see citing works
Diallo, A., Fonseca, L., & Holland, D. (2021) · Australian Journal of Rehabilitation Counselling · doi:10.1017/jrc.2021.8 · Cited by 6 · see citing works
“CBT has been effective in addressing dysfunctional thoughts in general (Lecomte et al., 2014; Lecomte et al., 2020; Geschwind et al., 2019) and in employment seeking situations (Diallo et al., 2013, 2015; Lee, 2019; Lindsay et al., 2015; McFarlane and Lynggaard, 2009).”
BackgroundKoo, H., Hoth, K. F., Make, B. J., Regan, E. A., Crapo, J. D., Silverman, E. K., & DeMeo, D. L. (2022) · Respiratory Research · doi:10.1186/s12931-021-01922-6 · Cited by 6 · see citing works
“However, positive CBT for optimism focuses on feeling positive emotion, being engaged at home and work, and experiencing positive relationships and accomplishments [41]; investigating optimism may provide an innovative intervention opportunity in conjunction with pulmonary rehabilitation to improve quality of life and…”
BackgroundHoffman, S. N., Lyons, R. C., Stein, M. B., Taylor, C. T., & Norman, S. B. (2022) · Behaviour Research and Therapy · doi:10.1016/j.brat.2022.104097 · Cited by 6 · see citing works
Jesús-Romero, R. D., Chimelis-Santiago, J. R., Rutter, L. A., & Lorenzo‐Luaces, L. (2024) · medRxiv · doi:10.1101/2024.06.28.24309661 · Cited by 6 · see citing works
“Geschwind et al. [44], for example, found faster symptom improvement when an initial negative-focus cognitive behavioral therapy (CBT) treatment phase was followed by a positive-focus CBT phase.”
BackgroundTargeting Positive Affect as a Way to Improve Social Anhedonia in Schizophrenia
Catalano, L. T., Patel, P. K., Weittenhiller, L. P., & Green, M. F. (2025) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaf117 · Cited by 5 · see citing works
Furman, B. W., Craighead, W. E., Mayberg, H. S., Mletzko, T., Nemeroff, C. B., & Dunlop, B. W. (2024) · Psychiatry Research · doi:10.1016/j.psychres.2024.115859 · Cited by 5 · see citing works
Dunn, B. D., Wiedemann, H., Kock, M., Peeters, F. P. M. L., Wichers, M., Hayes, R. A., Kuyken, W., & Geschwind, N. (2022) · Mindfulness · doi:10.1007/s12671-022-02032-0 · Cited by 5 · see citing works
“In other words, the superiority of MCBT-D over M-ADM in building PA was associated with a greater enhancement of sensory observing.”
BackgroundSelf-citationGeschwind, N., van Breukelen, G., & Lobbestael, J. (2019) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2019.101497 · Cited by 4 · see citing works
Self-citationChen, S., Zhao, W.-W., Cheng, Y., Bian, C., Yan, S.-R., & Zhang, Y. (2024) · Journal of Mental Health · doi:10.1080/09638237.2024.2332810 · Cited by 5 · see citing works
“…Spain (Chaves et al., 2017; Preschl et al., 2012), Canada (Sergeant & Mongrain, 2014), and the Netherlands (Bolier, Haverman, Kramer, et al., 2013; Geschwind et al., 2019), and in developing countries such as Iran (Asgharipoor et al., 2012) and China (Hwang et al., 2017; Kwok et al., 2016; Song…”
InfluentialPositive global mental health: an overview
Shin, J., Halbreich, U. M., & Jeste, D. V. (2025) · Academia Mental Health and Well-Being · doi:10.20935/mhealthwellb7578 · Cited by 4 · see citing works
Evaluating a Comprehensive Model of Euthymia
Vittengl, J. R., Jarrett, R. B., Ro, E., & Clark, L. A. (2023) · Psychotherapy and Psychosomatics · doi:10.1159/000529784 · Cited by 4 · see citing works
Prause, N., & Siegle, G. J. (2022) · Sexual Health · doi:10.1071/sh21219 · Cited by 4 · see citing works
Zangri, R. M., Roca, P., Blanco, I., Kulis, M., Díez, G. G., Martín-Subero, J. I., & Vázquez, C. (2024) · Mindfulness · doi:10.1007/s12671-024-02410-w · Cited by 3 · see citing works
“This approach aligns with the standard practice in psychological studies conducting a crossover design (e.g., Geschwind et al., 2019).”
Conde, A. R., de Sousa, C. N. S., da Silva, F. F., Souto, T., Fernandes, M. I., & Ferreira, M. J. (2024) · The Journal of Psychology · doi:10.1080/00223980.2024.2431204 · Cited by 3 · see citing works
“…based on positive psychology focused on promoting positivity, such as Positive Cognitive behavioral therapy and Strengths-based approaches (Geschwind et al., 2019; Proctor, 2017), Acceptance and Commitment Therapy (ACT) (Twohig & Levin, 2017) and Mindfulness (Nekić, 2023; Rogers & Maytan,…”
Bishop, L. S., & Reed, K. M. P. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.104008 · Cited by 3 · see citing works
Díez, G. G., Martin-Subero, I., Zangri, R. M., Kulis, M., Andreu, C. I., Blanco, I., Roca, P., Cuesta, P., García, C., Garzón, J., et al. (2023) · medRxiv · doi:10.1101/2023.03.03.23286782 · Cited by 3 · see citing works
Tönis, K. J. M., Velikova, S. R., Drossaert, C. H. C., ten Klooster, P. M., Staal, W., & Bohlmeijer, E. T. (2025) · Research in Neurodiversity · doi:10.1016/j.rin.2025.100009 · Cited by 2 · see citing works
Chinchilla-Fonseca, P., Marín-Picado, B., Moncada‐Jiménez, J., & Solórzano, A. M. J. (2022) · Revista de Psicología Aplicada al Deporte y el Ejercicio Físico · doi:10.5093/rpadef2022a7 · Cited by 5 · see citing works
Varlık, S. (2023) · Pamukkale University Journal of Education · doi:10.9779/pauefd.1229569 · Cited by 2 · see citing works
Kalamatianos, A., Kounenou, K., & Pezirkianidis, C. (2025) · Healthcare · doi:10.3390/healthcare13050511 · Cited by 2 · see citing works
“It has also been suggested that the augmentation of CBT’s efficacy may be attained by focusing on positive mental health and including themes, such as strengths and life-goals [44] and by emphasizing positive features [45] and well-being [46].”
Affect and post-COVID-19 symptoms in daily life: An exploratory experience sampling study
Schaap, G., Wensink, M., Doggen, C. J. M., van der Palen, J. A. M., Vonkeman, H. E., & Bode, C. (2024) · PLoS ONE · doi:10.1371/journal.pone.0295217 · Cited by 2 · see citing works
Coopersmith, A. S., Wolkowitz, O. M., Mellon, S. H., Wu, G. W. Y., Rampersaud, R., Hansen, N., Dutcher, E. G., Reus, V. I., & Mayer, S. E. (2024) · The Journal of Positive Psychology · doi:10.1080/17439760.2024.2427577 · Cited by 1 · see citing works
“While causality cannot be inferred from our data, it is possible that psychological therapies aimed at increasing optimism (e.g. positive CBT) may augment antidepressant responses and may yield superior outcomes compared to traditional CBT (Geschwind et al., 2019, 2020).”
Psychotherapy Modalities for Premenstrual Change: A Systematic Review
Buys, M. E. (2025) · Women & Therapy · doi:10.1080/02703149.2025.2534636 · Cited by 1 · see citing works
“Positive-orientated CBT emphasizes the positive aspects of a client’s presenting situation, and seeks to develop optimism, positive thinking, and positive emotions (Geschwind et al., 2019).”
Versluis, Y., Bol, Y., Peeters, F. P. M. L., & Bouwmeester, S. (2025) · British Journal of Guidance and Counselling · doi:10.1080/03069885.2025.2484222 · Cited by 1 · see citing works
“With a medium to large effect size (Geschwind et al., 2019; Skewes et al., 2015), ten participants and a range of seven days of possible start moments of the intervention lead to an expected power ranging from .71 to .92 (SD = .02).”
Self-citationStoia, M., Balázsi, R., Crișan, Ș., Miu, A. C., & Szentágotai‐Tătar, A. (2025) · Nature Mental Health · doi:10.1038/s44220-025-00532-1 · Cited by 2 · see citing works
“Specific interventions have been increasingly developed in recent years, such as the Mindfulness-Oriented Recovery Enhancement 50 , positive cognitive-behavioral therapy 51 , positive psychology interventions 52 and neurocognitive training 53,54 , and the evidence is encouraging 12 .”
Liang, H., Xiang, Y., Long, Y., LIWen-jian, & Zhang, L. (2025) · Behaviour Research and Therapy · doi:10.1016/j.brat.2025.104947 · Cited by 1 · see citing works
Learning from experience: Depressive bias and updating beliefs about common life events
Maffly‐Kipp, J., Strunk, D. R., Zhou, R. J., & Fournier, J. C. J. (2026) · Behaviour Research and Therapy · doi:10.1016/j.brat.2026.104959 · Cited by 1 · see citing works
Identifying what works in mental health apps through meta-regression analyses of 169 trials
Kraiss, J. T., Fiß, F., Chakhssi, F., Aktas, F. B., Koelen, J. A., & Simões, J. P. (2026) · npj Digital Medicine · doi:10.1038/s41746-026-02466-z · Cited by 1 · see citing works
Takahashi, T., Takebayashi, Y., Matsubara, K., Inaba, Y., Kawasaki, Y., & Sato, S. (2022) · Cognitive Therapy and Research · doi:10.1007/s10608-022-10326-9 · Cited by 1 · see citing works
Comprehensive Treatment of Depression: As Simple as the A-B-C’S
Overholser, J. C., & Peak, N. J. (2020) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-020-09458-4 · Cited by 1 · see citing works
“Clients can learn to shift their focus from problems to possible solutions (Geschwind et al. 2019).”
BackgroundTPH2: A Key Gene Risk Factor and Potential Therapy Target in Depression
Zhang, X., & Wang, Y. (2021) · E3S Web of Conferences · doi:10.1051/e3sconf/202127103070 · Cited by 1 · see citing works
حنور, ق. ع. خ. (2019) · مجلة كلية التربية جامعة بنها · doi:10.21608/jfeb.2018.61548
Леонардовна, Б. Г., & Александрович, Г. И. (2021) · Психология Журнал Высшей школы экономики · doi:10.17323/1813-8918-2021-2-317-337
Addictions et groupes spécifiques : les adolescents, les personnes âgées et les femmes
Graziani, P., & Romo, L. (2023) · Elsevier eBooks · doi:10.1016/b978-2-294-77964-0.00005-2
Hashimoto, K., Takeuchi, T., Tanobe, K., Takeda, N., Koyama, A., & Hashizume, M. (2024) · Research Square · doi:10.21203/rs.3.rs-4453398/v1
Sánchez-Cisneros, D., Hernández, G., Lugo, C. S. J., Vargas, A. E. O., & Pérez, V. F. (2024) · Interacciones Revista de Avances en Psicología · doi:10.24016/2024.v10.415
“También se identifica la prevalencia de modelos terapéuticos Nota: ⊕ : si aborda el tema; -: no aplica; PP: Psicoterapia Positiva; TAC: Terapia de aceptación y compromiso; TB: Terapia del bienestar (Geschwind et al., 2019).”
BackgroundInfluentialHow does CBT work on recovery from depression through positive affect route?
Ito, Y., Otsuka, S., Suwa, T., Yoshihara, Y., Kyuragi, Y., Hatakoshi, M., & Murai, T. (2025) · Current Psychology · doi:10.1007/s12144-025-07972-z
“These results were consistent with previous findings regarding the effects of CBT on depression (Bruijniks et al., 2022 ; Geschwind et al., 2019 ).”
Wang, X., Wang, M., & Li, H. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1440755
Die Perspektive wechseln: wie positives Denken hilft, den Schmerz zu besiegen
Boselie, J. J. L. M., & Peters, M. L. (2025) · Studien zur Resilienzforschung · doi:10.1007/978-3-658-44909-4_6
When CBT ‐I Falls Short: Why Solution‐Focused Therapy Deserves Attention in Insomnia Research
Carpi, M., & Szkody, E. M. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70216
“…depression and integrated with SFT techniques and concepts from positive psychology (positive CBT, P-CBT) yielded greater improvement in depressive symptoms than traditional, problem-focused CBT in a crossover randomised trial of 49 patients with major depressive disorder (Geschwind et al. 2019).”
Zangri, R. M., Roca, P., Blanco, I., Baliyan, S., & Vázquez, C. (2025) · Cognitive Therapy and Research · doi:10.1007/s10608-025-10662-6
García, F. E., Vázquez, C., Félix Cova, S., Beyebach, M., Rincón, P., Demarzo, M., Aravena, V., Cerna, C., Bruna, B., Włodarczyk, A., et al. (2025) · Applied Psychology Health and Well-Being · doi:10.1111/aphw.70108
Lai, Y.-J., Sangpara, J., Wankrathok, S., Cu, C., Yu, S.-C., Patel, A., Chen, H., Zhang, Y., Shen, J., & Wang, Y. Q. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1778010
“This pattern is consistent with the broader PPI and PCBT literature, which often reports strong immediate gains that level off without continued practice or booster sessions (Geschwind et al., 2019; Lyubomirsky and Layous, 2013).”
InfluentialNombela, E., Duque, A., Salgado, G., & Chaves, C. (2026) · Journal of Happiness Studies · doi:10.1007/s10902-026-01114-3
“Some approaches even propose that combin - ing CBT and PPI (i.e., positive CBT) may enhance treatment outcomes (Geschwind et al., 2019 ).”
- Authors
- Geschwind, N., Arntz, A., Bannink, F., & Peeters, F.
- Affiliations
- Maastricht University (NL)
- Maastricht University Medical Centre (NL)
- Corresponding author
- Geschwind, Nicole
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2019-05
- Volume
- 116
- Pages
- 119-130
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2922454181
- Cited by
- 79
- References
- 69
- Citations by year
- 2026: 4 · 2025: 15 · 2024: 14 · 2023: 12 · 2022: 10 · 2021: 13 · 2020: 4 · 2019: 7
- FWCI
- 10.02
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, other-oa)
- UvA-DARE (University of Amsterdam) (submittedVersion, other-oa)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- major depressive disorder, positive emotions, positive mental health, positive psychology interventions, solution-focused therapy, depressive symptoms, positive affect, optimism, happiness, reliable change
- MeSH terms
- Adult, Depressive Disorder, Major, Major Depressive Disorder, Female, Humans, Male, Middle Aged, Cognitive Behavioral Therapy, Cross-Over Studies, Young Adult
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