Positive Affect Therapy (PAT) represents a paradigm shift in the treatment of mood and anxiety disorders, moving beyond symptom reduction to actively cultivate positive emotional states.
Emerging from advances in behavioral neuroscience and positive psychology, PAT targets the core deficits in reward processing that underlie anhedonia—a persistent loss of pleasure or interest that predicts poor prognosis, treatment resistance, and suicidality (Craske et al., 2016). Traditional cognitive-behavioral therapy (CBT), while effective for reducing negative affect, has shown limited success in enhancing positive affect (Craske et al., 2019). This gap led to the development of PAT, which prioritizes the amplification of reward sensitivity through structured behavioral, cognitive, and emotional exercises (Fredrickson, 2001).
Theoretical Foundations of Positive Affect Therapy
PAT operates on the premise that chronic depression and anxiety stem from dysregulated reward systems rather than excessive negative affect alone. Neuroimaging studies reveal that individuals with anhedonia exhibit blunted neural responses to rewarding stimuli in regions such as the ventral striatum and prefrontal cortex (Feldman, Joormann, & Johnson, 2008). The ventral striatum and prefrontal cortex graphic © Fernando Da Cunha/Science Photo Library.
PAT addresses this by targeting three components of reward processing: anticipation-motivation (the drive to pursue rewards), initial responsiveness (the ability to experience pleasure in the moment), and reward learning (the capacity to associate actions with positive outcomes; Craske et al., 2016).
Unlike CBT, which focuses on modifying maladaptive thoughts and behaviors linked to distress, PAT deliberately avoids challenging negative cognitions. Instead, it trains patients to attend to positive aspects of their experiences, reframe achievements as personally meaningful, and savor positive emotions (Fredrickson, 2001). Mature skater © insta_photos/Shutterstock.com.
This approach aligns with the broader principles of positive psychotherapy, emphasizing a balance between positive and negative emotional states (Sin & Lyubomirsky, 2009). However, PAT diverges by incorporating neuroscientifically informed techniques to stimulate underactive reward pathways directly. For example, behavioral activation in PAT is augmented by imaginal recounting—a practice where patients vividly relive positive experiences to reinforce hedonic impact and attentional bias toward rewarding stimuli (Craske et al., 2019).
Clinical Implementation of PAT
PAT unfolds over 15 weekly sessions structured into three modules: Actions Toward Feeling Better, Attending to the Positive, and Building Positivity. The first module combines behavioral activation with imaginal recounting to enhance reward anticipation. Patients design personalized rewarding activities, such as reconnecting with a hobby or engaging in social interactions, and subsequently recount these experiences in detail during sessions to amplify their emotional resonance (Craske et al., 2019). Therapists guide patients to focus on sensory details and positive emotions, countering the tendency to dismiss or minimize positive moments (Sin & Lyubomirsky, 2009).
The second module trains cognitive skills to redirect attention toward positive stimuli. Exercises like Finding the Silver Linings encourage patients to identify multiple positive aspects of neutral or challenging situations while Taking Ownership helps them recognize their agency in generating positive outcomes (Fredrickson, 2001). For instance, a patient might reflect on how their initiative at work led to a colleague’s praise, fostering feelings of pride and competence. These exercises aim to recalibrate attentional biases that typically favor negative information in depressive states (Feldman et al., 2008).
The final module, Building Positivity, introduces practices such as gratitude journaling, acts of kindness, and loving-kindness meditation to cultivate enduring positive emotions. Patients learn to “savor” everyday pleasures through mindfulness techniques, such as mentally extending moments of joy during a morning coffee or sunset walk (Fredrickson, 2001). Unlike CBT’s problem-solving focus, PAT’s interventions exclusively target the amplification of positive affect, hypothesizing that this will indirectly reduce negative affect by diminishing its cognitive and emotional dominance (Craske et al., 2019).
Efficacy Compared to Cognitive-Behavioral Therapy
Randomized controlled trials demonstrate PAT’s superiority over traditional CBT approaches in improving positive affect and reducing relapse rates (Craske et al., 2019). In a two-site trial comparing PAT to Negative Affect Treatment (NAT)—a CBT variant targeting threat sensitivity—PAT participants showed significantly greater increases in positive affect (d = 0.67) and larger reductions in depression (d = 0.34), anxiety (d = 0.30), and stress (d = 0.43) at 6-month follow-up (Craske et al., 2019). Crucially, only 1.7% of PAT patients reported suicidal ideation post-treatment versus 12.0% in the NAT group, underscoring its protective effects against severe outcomes.
While CBT achieves moderate effect sizes (Hedges’ g ≈ 0.70) for acute symptom relief, up to 50% of patients relapse within 2 years due to residual anhedonia and poor reward system engagement (Hollon et al., 2005). PAT’s emphasis on sustained positive emotion cultivation appears to address this limitation. Longitudinal data indicate that PAT’s benefits persist at 6 months, with patients maintaining higher levels of positive affect and lower symptom severity than those receiving NAT (Craske et al., 2019).
Emerging therapies like Augmented Depression Therapy (ADepT) share similarities with PAT but expand the focus to address both positive and negative emotions simultaneously. ADepT emphasizes solution-focused strategies, helping patients recognize and dismantle thought patterns that hinder personal goals (Russo, 2025). Early research indicates that ADepT outperforms CBT in reducing depressive symptoms, with sustained benefits at a 12-month follow-up.
Mechanisms and Long-Term Benefits
PAT’s efficacy correlates with measurable changes in reward processing. Behavioral tasks reveal that PAT enhances reward anticipation (e.g., increased effort expenditure for potential rewards) and initial responsiveness (e.g., heightened physiological arousal to pleasant stimuli) (Feldman et al., 2008). Neuroimaging studies suggest that these behavioral shifts correspond to increased ventral striatum and medial prefrontal cortex activation during reward tasks (Fredrickson, 2001). By contrast, CBT primarily modulates amygdala hyperactivity and prefrontal regulation of threat responses, which may explain its weaker impact on anhedonia (Hollon et al., 2005). The medial prefrontal cortex graphic was adapted from Wikipedia by minaanandag at Fiverr.com.
The therapy’s focus on reward learning also promotes resilience. Patients learn to associate self-generated actions with positive outcomes, reinforcing adaptive behaviors. For example, a patient who initiates a social outing and subsequently experiences joy begins to perceive social engagement as rewarding, creating a self-sustaining cycle of positive reinforcement (Craske et al., 2016). This mechanism may account for PAT’s lower relapse rates, as patients develop intrinsic motivation to seek out and savor rewarding experiences autonomously (Craske et al., 2019).
A significant barrier to focusing on positive experiences is the phenomenon of contrast avoidance—the fear that experiencing happiness will lead to a painful fall when adversity strikes (Russo, 2025). New interventions like the SkillJoy app encourage users to identify, savor, and sustain positive feelings throughout the day, reducing contrast avoidance and strengthening emotional resilience.
Key Takeaways
Positive Affect Therapy (PAT) focuses on enhancing positive emotions to promote psychological resilience by targeting reward system deficits, such as those found in individuals with anhedonia, rather than merely reducing negative symptoms.
PAT differs from Cognitive Behavioral Therapy (CBT) by emphasizing the cultivation of positive experiences, such as joy, gratitude, and personal achievement, rather than challenging negative cognitions directly.
PAT uses a structured, three-module approach—Actions Toward Feeling Better, Attending to the Positive, and Building Positivity—to improve reward anticipation, emotional responsiveness, and reward learning through practices like gratitude journaling and mindfulness-based savoring.
Research suggests PAT outperforms CBT in enhancing positive affect and reducing relapse rates, particularly in treating depression and anxiety, with evidence showing a significant reduction in suicidal ideation among PAT participants.
PAT’s focus on reward processing and intrinsic motivation may offer long-term psychological benefits, making it a valuable alternative or complement to traditional therapies like CBT, particularly for individuals with low positive affect or treatment-resistant symptoms.
Conclusion
Positive Affect Therapy offers a compelling alternative to CBT for individuals with depression and anxiety characterized by anhedonia and low positive affect. Its theoretical grounding in reward neuroscience and structured interventions to enhance anticipation, responsiveness, and learning address critical gaps in traditional approaches. While CBT remains effective for reducing acute distress, PAT’s unique focus on positivity cultivation provides durable protection against relapse and suicidality. Future research should explore PAT’s applicability across cultures and its integration with pharmacological treatments targeting dopaminergic pathways.
Glossary
affect: a psychological term referring to the experience of feeling or emotion, encompassing both positive and negative emotional states.
anhedonia: a psychological condition characterized by the inability to experience pleasure from normally rewarding activities, commonly associated with depression and other mood disorders.
anticipation-motivation: a component of reward processing that involves the drive to pursue pleasurable or rewarding experiences.
Augmented Depression Therapy (ADepT): a psychotherapeutic intervention designed to enhance both positive and negative affect regulation through solution-focused strategies. It aims to help patients identify and dismantle thought and behavioral patterns that hinder personal goals, fostering both emotional resilience and functional improvement.
behavioral activation: a therapeutic technique that encourages individuals to engage in enjoyable or meaningful activities to counteract depression and enhance positive feelings.
cognitive-behavioral therapy (CBT): an evidence-based psychotherapeutic approach focused on identifying and restructuring maladaptive thoughts and behaviors to alleviate psychological distress.
cognitive bias: a systematic pattern of deviation from norm or rationality in judgment, often contributing to emotional or psychological distress.
cognitive restructuring: a core CBT technique that involves identifying, challenging, and modifying distorted or maladaptive thought patterns.
cognitive therapy: a type of psychotherapy that focuses on changing unhelpful cognitive distortions and emotional responses.
contrast avoidance: a psychological phenomenon where individuals fear experiencing positive emotions because they believe that feeling happy will be followed by a sudden negative event. This often leads to the suppression of positive feelings to avoid emotional vulnerability or disappointment.
depression: a common mental health disorder characterized by persistent sadness, lack of interest or pleasure, and other symptoms that interfere with daily functioning.
distress: negative stress that can lead to psychological and physical problems if not managed effectively.
emotional resilience: the ability to adapt to stressful situations or adversity, maintaining psychological well-being.
emotional responsiveness: the capacity to experience and react to emotional stimuli, particularly positive or rewarding experiences.
fear contrast avoidance: a specific form of contrast avoidance where individuals believe that anticipating negative outcomes or remaining in a state of worry will prevent future disappointment, particularly common in anxiety disorders.
gratitude journaling: a therapeutic exercise where individuals regularly document things they are grateful for, which can enhance well-being and positive emotions.
imaginal recounting: a therapeutic practice in which individuals vividly recall positive experiences to reinforce positive emotions and attentional biases toward rewarding stimuli.
maladaptive cognition: dysfunctional thought patterns that contribute to emotional distress and psychological disorders.
mindfulness: a mental practice focusing on maintaining moment-to-moment awareness of thoughts, feelings, bodily sensations, and the surrounding environment.
neuroimaging: the use of various technologies, such as MRI or PET scans, to visualize the structure, function, or pharmacology of the brain.
neuroscientifically informed techniques: therapeutic practices based on scientific research related to brain structure and function.
positive affect: the extent to which an individual feels enthusiastic, active, and alert, encompassing emotions such as joy, interest, and contentment.
positive affect therapy (PAT): a psychotherapeutic intervention aimed at increasing positive emotions and reward sensitivity, particularly for individuals with mood and anxiety disorders.
positive experiences savoring: a therapeutic practice where individuals consciously focus on and mentally extend positive experiences, emphasizing sensory and emotional details to intensify feelings of joy and satisfaction.
positive psychology: a field of psychology focused on studying human strengths, virtues, and factors that contribute to happiness and well-being.
positive psychotherapy: is a therapeutic approach that emphasizes fostering positive emotions, meaning, and personal strengths to promote mental well-being.
prefrontal cortex: a brain region involved in higher-order cognitive processes, such as decision-making, social behavior, and emotional regulation.
reward anticipation: the motivational component of reward processing, involving the expectation or pursuit of pleasurable outcomes.
reward learning: the process by which individuals learn to associate specific behaviors or actions with positive outcomes.
reward processing: neural mechanisms that drive motivation, pleasure, and learning from positive outcomes.
reward sensitivity: the degree to which an individual's brain responds to rewarding stimuli. Low reward sensitivity is often associated with anhedonia, depression, and anxiety, while high sensitivity can promote positive emotional experiences and motivation.
savoring: a mindfulness-based technique that involves consciously enjoying and extending the experience of positive emotions.
SkillJoy: a digital intervention designed to help users recognize and savor positive experiences throughout the day. The app encourages users to stay with positive feelings for longer periods, aiming to reduce contrast avoidance and promote emotional well-being.
suicidality: the risk or occurrence of suicidal thoughts, behaviors, or attempts.
threat sensitivity: the degree to which an individual perceives and responds to potential threats in their environment, often heightened in anxiety disorders.
ventral striatum: a subcortical brain region involved in reward processing, motivation, and reinforcement learning. It primarily includes the nucleus accumbens and olfactory tubercle, connecting to other limbic structures such as the amygdala and ventral pallidum.
well-being: a holistic concept encompassing psychological, emotional, and physical health, often measured by life satisfaction, happiness, and emotional balance.
References
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.
Craske, M. G., Meuret, A. E., Ritz, T., Treanor, M., & Dour, H. J. (2016). Positive affect treatment for depression and anxiety: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(7), 531–545. https://doi.org/10.1037/ccp0000091
Craske, M. G., Meuret, A. E., Ritz, T., Treanor, M., & Dour, H. J. (2019). Positive affect treatment for depression and anxiety. Journal of Consulting and Clinical Psychology, 87(5), 435–453. https://doi.org/10.1037/ccp0000396
Feldman, G. C., Joormann, J., & Johnson, S. L. (2008). Responses to positive affect: A self-report measure of rumination and dampening. Cognitive Therapy and Research, 32(4), 507–525. https://doi.org/10.1007/s10608-006-9083-0
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56(3), 218–226. https://doi.org/10.1037/0003-066X.56.3.218
Hollon, S. D., Stewart, M. O., & Strunk, D. (2005). Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Annual Review of Psychology, 57, 285–315. https://doi.org/10.1146/annurev.psych.57.102904.190044
Positive Affect Treatment Targets Reward Sensitivity Trial Protocol. (2022, March 31). ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT03439748
Positive Affect Treatment for affective disorders [Workshop]. (2023). ABCT eLearning. https://elearning.abct.org/products/recorded-mini-workshop-13-positive-affect-treatment-for-affective-disorders-2023-convention-recording
Russo, F. (2025). New psychotherapies that focus on positive experiences could better treat depression and anxiety. Scientific American. https://www.scientificamerican.com/article/new-psychotherapies-that-focus-on-positive-experiences-could-better-treat-depression-and-anxiety/
Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology, 65(5), 467–487. https://doi.org/10.1002/jclp.20593
What is positive psychotherapy? (2024, December 4). PositivePsychology.com. https://positivepsychology.com/positive-psychotherapy-research-effects-treatment/
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