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Journal of
Cognitive
Psychotherapy:
An International Quarterly
Volume 20, Number 2 • 2006
On the Integration of
Cognitive-Behavioral Therapy for
Depression and Positive Psychology
Leslie Karwoski, MA
Genevieve M. Garratt, MA
Stephen S. Ilardi, PhD
University of Kansas, Lawrence
Cognitive-behavior therapy (CBT) has received extensive empirical support as an efficacious
intervention for the acute treatment of major depressive disorder and the prevention of
depressive relapse. Nevertheless, many patients do not respond favorably to CBT, and the
specific active ingredients of CBT remain unclear. Vv'ith its emphasis on identifying and cul-
tivating individual strengths, however, positive psychology appears to have considerable po-
tential to enhance the efficacy of CBT and to help clarify the processes that mediate its
salubrious effects. We outline existing areas of conceptual and technical overlap between CBT
and positive psychology, and discuss how CBT may be extended and improved through the
incorporation of positive psychological principles.
Keywords: cognitive-behavioral therapy (CBT); integration; positive psychology; depression
T
he lifetime prevalence of major depressive illness in the United States is estimated at
nearly 20% (Kessler et al., 1994), and the risk of depression appears to be steadily in-
creasing
among younger age cohorts (e.g., Garber & Flynn, 2001). Because depression
commonly engenders substantial impairment of both occupational and social functioning, it
ranks among the most costly and debilitating of illnesses worldwide (Keller & Boland, 1998).
Indeed, an increased public recognition of the devastating personal and financial toll of de-
pression has helped catalyze in recent decades a burgeoning research effort to identify effective
acute and prophylactic psychological interventions for this disorder, and the most intensively
researched of these, by far, is Aaron Beck's (1967) cognitive-behavioral therapy (CBT).
The two principal treatment goals of CBT are: (a) teaching patients to modify their dys-
functional thoughts as a means of ameliorating depressive symptomatology; and (b) endowing
patients with a set of enduring cognitive skills to reduce the risk of subsequent relapse. Numerous
published controlled clinical trials have documented the acute efficacy of CBT (reviewed in
Craighead, Hart, Craighead, & Ilardi, 2002)—an efficacy that appears to be comparable in
magnitude to that of antidepressant medication (Gloagen, Cottraux, Cucherat, & Blackburn,
1998).
Approximately two-thirds of depressed individuals treated with CBT will evidence a
2006 Springer Publishing Company 159
160 CBT and Positive Psychology
favorable short-term response, and the posttreatment risk of relapse among CBT responders
appears to be considerably lower than that found among patients treated solely with antide-
pressant medication (Young, Weinberger, & Beck, 1999).
Although such findings have helped establish Beck's CBT for depression as one of the most
rigorously supported of all psychosocial interventions, it remains the case that a substantial
subset of individuals who undertake CBT do not get well. Indeed,/ewer than half of those who
enter CBT treatment will experience complete and long-lasting recovery from their depressive
symptoms (e.g., Elkin et al., 1989). Additionally, despite several decades of intensive research
aimed at identifying the active ingredients of CBT, the precise mediational mechanisms of
change within this intervention remain poorly understood (e.g., Ilardi & Craighead, 1999), We
believe, however, that the emerging field of positive psychology—with its emphasis on the
cultivation of existing and latent strengths—offers promise in (a) clarifying why CBT is a par-
ticularly efficacious intervention for depression, and (b) identifying how the protocol may be
refined and improved. As Seligman (2002) has suggested, "positive psychology, albeit intuitive
and inchoate, is a major effective ingredient in therapy as it is now done; if it is recognized and
honed, it will become an even more effective approach to psychotherapy" (p. 6).
In this article, we will detail the considerable conceptual and technical overlap between CBT
and positive psychological approaches. We will then discuss specific ways in which elements
drawn from positive psychology may be used to enhance the efficacy of CBT.
Conceptual Overlap
Although the CBT protocol is amenable to some degree of modification and tailoring to suit
each specific patient (Beck, Rush, Shaw, & Emery, 1979), there are a number of foundational
principles that underlie all CBT interventions. In this regard, Judy Beck (1995) has identified a
set often core CBT principles, many of which (as outlined below) share considerable conceptual
overlap with positive psychological approaches.
Establishing a Strong Therapeutic
Alliance.
The cultivation of
a
strong positive therapeutic
alliance between the patient and therapist is held as a necessary, though not sufficient, condition
for the effective implementation of CBT (Beck et al., 1979). Specifically, such an alliance is
considered an essential precursor to the effective implementation of cognitive and behavioral
interventions. Positive psychological theorists likewise have emphasized the importance of es-
tablishing a therapeutic alliance as a means of facilitating subsequent therapeutic gains (e.g.,
Keyes & Lopez, 2002). However, whereas Beck and his colleagues generally have viewed the
therapeutic alliance as merely a means to an end (i.e., the alliance helps facilitate the work of
cognitive restructuring—CBT's hypothesized active ingredient), positive psychologists are more
inclined to regard it as a worthwhile therapeutic goal in and of itself (Seligman, 1998). This
latter stance is consistent with emerging evidence that the quality of the therapist-patient rela-
tionship accounts for a large proportion of treatment outcome variance across a wide range of
interventions and disorders (e.g., Lambert, 1992; Summers & Barber, 2003).
Focus on Discrete Goals. CBT maintains a distinctive focus on the therapist and patient
working toward a set of clearly specified goals. Similarly, positive psychologists have emphasized
that the process of striving after meaningful goals may promote the experience of positive affect
(e.g., Snyder et al., 1996; Watson, 2002). Hence, positive psychology and CBT both underscore
the need to be working toward discrete goals as integral to the therapeutic process.
Focus
on
the
Here-and-Now. Beck (1995) suggests that CBT has as its focus the amelioration
of current problems, with material from the past addressed only inasmuch as it subserves the
aim of improving the here-and-now. This emphasis on the present is congruent with that of
several positive psychological interventional approaches. For example, mindfulness meditation
involves fully attending to the present moment (Langer, 2002), and optimal flow experiences
Karwoski et al. 161
reflect complete attentional absorption in the present rather than the past (Nakamura
&
Csiksz-
entmihalyi, 2002).
Cognitive
Reappraisal.
Teaching depressed patients to identify overly negative thought pro-
cesses and to replace such thoughts with more realistic appraisals of ongoing events is the sine
qua
non
of CBT (Beck et al., 1979). Indeed, cognitive modification is hypothesized as the primary
means of reducing the intensity of negative affective states. This reappraisal process is congruent
with the positive psychology construct of reality negotiation (Higgins, 2002; Snyder, 1989; Sny-
der & Higgins, 1988), which requires the individual to consider alternative interpretations of
events, and oftentimes entails a modification of original appraisals in favor of slightly positively
biased (albeit workable) ones. Likewise, the cultivation of mindfulness (Langer, 2002) includes
an implicit element of reappraisal, inasmuch as it involves merely
observing
thoughts and feel-
ings,
without becoming attached to them, as a means of facilitating less negatively biased and
distorted perspectives on events.
Patient as Collaborative Partner. The CBT patient is viewed as a full and active partner in
the therapeutic collaboration. In essence, the patient is trained to become his or her own ther-
apist, a process that is hypothesized to reduce the risk of posttreatment relapse (Beck, 1995).
Positive psychological interventions also tend to emphasize active patient engagement with the
treatment process (e.g., Thompson, 2002), although the rationale for such an emphasis is typ-
ically somewhat different from that found within CBT. According to Thompson (2002), for
example, the goal of this process is to help patients experience the positive psychological and
physical health benefits derived from therapeutic collaborations that enhance their perceived
personal control.
Overlap of Technique
The positive psychology movement has integrated numerous concepts and therapeutic tech-
niques drawn from an array of distinctive psychotherapeutic approaches, including many that
derive from Beck's CBT. Moreover, although the primary aim of CBT is to reduce symptoms
(i.e.,
an apparently negative rather than a positive focus), there are several CBT-based techniques
that are congruent with the positive psychology aim of building on the patient's existing strengths
to enhance emotional well-being. In this section, we describe a set of CBT techniques with
strong similarities to positive psychological interventions.
Pleasant Activities Scheduling. Within the first few treatment sessions, the CBT patient
typically is encouraged to identify and schedule a number of subjectively pleasurable daily ac-
tivities. Patients initially are asked to monitor their daily activities and to rate each one for its
corresponding level of pleasure and perceived accomplishment. Those activities rated as plea-
surable are subsequently scheduled with greater frequency as a means of inducing positive affect
(Beck, 1995). This approach is consistent with the thrust of a burgeoning positive affectivity
literature, in which it is emphasized that "high levels of positive mood are most likely when a
person is focused outward and is actively engaging the environment" (Watson, 2002, p. 117).
Identifying and Reviewing
Success
Experiences.
Because depression is typically characterized
by a pervasive sense of helplessness, CBT patients often are asked to identify and review their
experiences of success (Beck, 1995). Within the positive psychology literature, this process has
been described in terms of enhancing the patient's self-efficacy in target domains (Maddux,
2002).
Indeed, the CBT protocol—by virtue of its collaborative emphasis on setting and moni-
toring progress toward attainable short-term patient goals—appears well-suited to enhancing
the patient's perceived efficacy (Ilardi & Craighead, 1994).
Mood Monitoring. CBT patients may be asked to keep a chart detailing the mood states
that characterize various daily activities (Beck, 1995). Such mood tracking has been hypothesized
to subserve the positive psychological aim of increasing positive affectivity. "By monitoring our
162 CBT and Positive Psychology
moods and becoming more sensitive to these internal rhythms, we should be able to maximize
feelings of efficacy and enjoyment, while minimizing stress and frustration" (Watson, 2002, p.
116).
Relaxation Training. Relaxation training is commonly presented in CBT as an optional
technique that may be used during treatment as a means of decreasing state anxiety (Beck,
1995).
However, the psychological benefits of relaxation training as a means of enhancing sub-
jective well-being have been well-documented (see Blumenthal, 1985), and numerous methods
of inducing relaxation, such as imagery exercises, progressive muscle relaxation, meditation, and
yoga, have been employed in the treatment of a variety of psychological disorders. From a
positive psychological vantage point, relaxation training may be viewed as a particularly effective
technique to enhance one's sense of contentment, and thereby to "build enduring psychological
resources and trigger upward spirals toward emotional well-being" (Frederickson, 2002, p. 127).
Problem-Solving. Problem-solving training often is introduced as early as the first CBT
session as a means of helping the depressed patient gain enhanced confidence in his or her
ability to formulate solutions to target problems (Beck et al., 1979). The desirability of problem-
solving training also has been discussed within the positive psychology literature. For example,
a growing body of empirical research supports the claim that a shift toward more positive
problem-solving appraisals (i.e., the perceived ability to solve existing problems) is associated
with an improvement in depressive symptoms (reviewed in Heppner & Lee, 2002).
POSITIVE
PSYCHOLOGY
AND THE
ENHANCEMENT
OF CBT
A cardinal principle of positive psychology is that psychologists should not just "fix" people's
problems; rather, they also should assist them in achieving fuller, richer, and happier lives. As
Seligman (2002) notes, the "aim of positive psychology is to catalyze a change in psychology
from a preoccupation only with repairing the worst things in life to also building the best
qualities in life" (p. 3). CBT focuses on repairing "the worst things in life," and it is quite
effective in doing so. Nonetheless, as noted previously, a sizable subset of depressed patients
treated with CBT do not achieve full and lasting recovery. Accordingly, we believe that CBT
may be improved through the incorporation of
a
more explicit positive psychological focus on
"building the best qualities in life." We now
will
discuss several possible directions for integrating
CBT and positive psychology.
Moving Beyond the Reduction of Negative Affectivity
Although the DSM diagnostic system classifies individuals solely on the basis of their identified
symptomatology, Keyes and Lopez (2002) have suggested that mental health may be concep-
tualized not only as the absence of psychopathology, but also as the presence of emotional well-
being. On this basis, they have proposed four categories for describing an individual's overall
mental health: (a)
flourishing,
for people with no diagnosable mental illness and a high level of
emotional well-being; (b)
languishing,
for nonmentally ill individuals who nonetheless experi-
ence a low overall sense of well-being; (c)
floundering,
for people with diagnosable mental illness
and a low level of well-being; and (d)
struggling,
for people who have diagnosable mental illness
and yet a high level of well-being. Accordingly, we observe that the mere removal of the patient's
acute depressive symptoms during therapy—the principal goal of CBT—is not sufficient to
guarantee the patient's flourishing state at posttreatment. Indeed, for the CBT patient whose
baseline level of functioning (prior to depression onset) has been characterized by generally
low positive affectivity, even the complete amelioration of depressive symptoms during acute
treatment will likely be sufficient only to return her to a languishing state upon treatment
Karwoski et al. 163
termination, inasmuch as the CBT protocol includes very little that directly addresses the pa-
tient's attenuated ability to cultivate positive affective states.
The CBT protocol appears implicitly to reflect the notion that a reduction of negative
affectivity (via modification of the patient's distorted negativistic cognitions) will be tantamount
to an increase in positive affectivity. It is becoming increasingly clear, however, that negative
and positive affectivity are largely orthogonal, independent constructs (Bradburn,
1969;
Watson
& Clark, 1997). An acute reduction in negative affect—again, the principal treatment goal of
CBT—does not necessarily induce a commensurate increase in positive affect (Diener, Lucas,
& Oishi, 2002). In a thoughtful review of the link between affectivity and depressive illness,
Clark and colleagues (1994) observed that low levels of positive affectivity predict both slower
recovery from depressive episodes and an increased risk of subsequent relapses. We believe,
therefore, that the acute and long-term efficacy of CBT can be enhanced by integrating principles
of positive psychology—specifically, those related to cultivating and enhancing positive affec-
tivity and overall well-being. In other words, symptom reduction is only a first step. Following
the amelioration of acute symptoms, "treatment may fruitfully pursue loftier goals of promotion
of quality of life and, possibly, flourishing in life" (Keyes & Lopez, 2002, p. 50).
Although there is a substantial genetic component to each individual's baseline level of
positive affectivity (Diener et al., 2002)—with perhaps as much as half of interperson variability
accounted for by genetic factors (Tellegen et al., 1988)—there still exists considerable potential
for intervention-induced change in perceived level of well-being. Diener et al. (2002) detail
several means of enhancing emotional well-being: the recognition of existing strengths; the
cultivation of flow experiences; the pursuit of meaningful goals; and the cultivation of hope,
optimism, and expected control. Following is a brief discussion of these factors as they pertain
to the treatment of depression in CBT.
Capitalizing
on
Strengths.
In a trenchant discussion of possible clinical extensions of positive
psychology, Wright and Lopez (2002) urge clinicians to move beyond an exclusive focus on
patient difficulties and deficits, and to take patient strengths into greater account during as-
sessments and treatments. There is, in fact, increasing evidence that empirically supported psy-
chotherapies for depression may owe their efficacy, at least in part, to an inadvertent capitali-
zation on existing patient strengths. For example, in the largest psychotherapy trial for the
treatment of depression conducted to date—the National Institute of Mental Health Treatment
of Depression Collaborative Research Program (Elkin et al., 1989)—differential response to
CBT or interpersonal psychotherapy (IPT) was predicted by patient strengths that matched the
targeted focus of each respective protocol. Specifically, favorable response to CBT was predicted
by
low
pretreatment levels of cognitive dysfunction (i.e., the pre-existence of the very cognitive
skills that serve as the focus of intervention), whereas high pretreatment levels of social skill-
fulness—the target of IPT intervention—predicted favorable treatment outcome in interper-
sonal psychotherapy (Elkin, 1994).
Indeed, it does not appear that CBT works primarily by effecting long-term change to
cognitive structures (Barber & DeRubeis, 1989)—that is, repairing patient cognitive dysfunc-
tion—but rather by capitalizing on existing patient cognitive abilities, albeit those that may
become temporarily compromised because of acute depressive symptoms. By extension, then,
we suggest that the CBT therapist would do well to conduct a thorough pretreatment assessment
of patient strengths across multiple domains (including the set of temporarily dormant strengths
that existed prior to the onset of the depressive episode), and to attend closely to emerging
opportunities to capitalize on such strengths throughout the treatment process. This will be an
especially important consideration for those patients whose high pretreatment levels of cognitive
dysfunction would otherwise predispose them to poor CBT treatment response.
Hope. The aforementioned finding—that CBT works best for those patients who would
appear to need its core cognitive interventions the least (see Rude
&
Rehm,
1991,
for a review)—
164 CBT and Positive Psychology
is not easily reconciled with Beck's (1967) cognitive model of depression. The finding is quite
congruent, however, with Snyder's hope
theory,
a positive psychological framework that details
the manner in which the cultivation of hope may work to reduce dysphoria and to induce
positive affectivity (Snyder, 2002; Snyder, Feldman, Taylor, Schroeder,
&
Adams, 2000). Because
hope is generated by the experience of movement toward meaningful goals, it follows that the
subset of CBT patients who are most readily capable of moving toward the primary therapist-
specified goal—that is, the goal of applying CBT's cognitive techniques—will be the very pa-
tients who experience the greatest surge in hope, and hence the greatest reduction in depressive
symptomatology. Indeed, on the basis of an extensive review of the extant CBT literature, Ilardi
and Craighead (1994, 1999) have concluded that the bulk of clinical improvement that occurs
in CBT may be attributable to the protocol's inadvertent induction of patient hopefulness rather
than to cognitive modification, per se. Building on the seminal work of Jerome Frank (1961),
these investigators note that CBT may be especially effective when the therapist works to accen-
tuate the hope-inducing elements of the CBT protocol, including: provision of
a
highly credible
treatment rationale, incorporation of specific and achievable patient homework assignments,
establishment of an empathic therapeutic alliance, and the therapist's ownership of the role of
expert and "culturally sanctioned healer" (Ilardi & Craighead, 1994).
Flow. Being fully absorbed in the present moment and enjoying an activity for its own
intrinsic rewards has been described as the experience of flow (Nakamura & Csikszentmihalyi,
2002).
The flow state most commonly occurs during somewhat challenging activities that require
a high level of skill and attentional engagement—for example, rock climbing, playing a musical
instrument, participating in emotionally meaningful conversation, painting, skiing, etc. Not only
do flow experiences tend to induce positive mood, but the amount of time spent in a state of
flow appears to be predictive of one's overall level of positive affectivity (Adlai-Gail, 1994).
Accordingly, clinical researchers have begun to explore the incorporation of flow-based tech-
niques in psychotherapy. For example, the Flow Questionnaire (Csikszentmihalyi & Csikszent-
mihalyi, 1988) may be used to identify activities that reliably induce a state of flow for the
depressed patient (or, at least, those that did so prior to the onset of depressive illness), with
the therapeutic aim of helping the patient cultivate more such activities (Nakamura & Csiksz-
entmihalyi, 2002). Despite the fact that the CBT protocol includes an optional set of techniques
that may be used to help patients identify and schedule a greater number of pleasant activities,
this process is not optimally designed to increase the CBT patient's experience of fiow on an
ongoing basis because: (a) many of the pleasant activities most commonly identified by patients
(e.g., watching a movie, taking a long bath, going for a walk, etc.) do not contain a sufficient
degree of intrinsic challenge to induce the fiow state; (b) activity scheduling is not regarded as
an essential element of the CBT protocol, and thus may not be included at all during any given
patient's course of treatment (Beck et al., 1979); and (c) even when activity scheduling is used,
it typically occurs only early in treatment, when the patient's depression-induced loss of energy
may preclude participation in more challenging, fiow-inducing activities. On the basis of the
aforementioned considerations, however, it would appear that only a slight modification of the
existing CBT pleasant activities component would be required to incorporate the cultivation of
fiow experiences into the existing CBT protocol.
Mindfulness. Mindfulness refers to a state of full awareness of the present moment (Kabat-
Zinn, 1990), and techniques designed to induce mindfulness already have been integrated into
several psychotherapeutic approaches, including dialectical-behavioral therapy (Linehan, 1993)
and
mindfulness-based cognitive therapy
(Segal, Williams,
&
Teasdale, 2002; Teasdale et al., 2000).
Although mindfulness training is of interest to positive psychologists for its value in promoting
a heightened sense of relaxation, alertness, and overall well-being, the cultivation of mindfulness
also has clear benefits in the treatment of many forms of psychopathology, including depression.
Because mindfulness may be viewed as a heightened state of attentional control, it has been
Karwoski et al. 165
found to be useful in combating the mindless rumination that typifies depressive and anxious
states.
Indeed, inasmuch as the process of ruminating about negatively themed events typically
escalates the intensity of existing negative mood states (e.g., Nolen-Hoeksema, 1991), mindful-
ness-based cognitive therapy is especially valuable as a means of teaching patients how to effec-
tively disengage from ruminative negative thoughts, thereby preventing the intensification of
negative mood. In fact, this therapeutic approach has been shown to reduce the risk of depression
relapse among patients with recurrent depression (Teasdale et al., 2000).
Addressing
Unsolvable
Problems.
Although CBT is effective in helping patients view situa-
tions more realistically, it offers little in the way of enabling patients to cope with situations
characterized by intrinsically
unsolvable
problems. For this subset of intractable life circum-
stances, CBT offers little beyond helping patients address the possible occurrence of any irra-
tional (i.e., overly negativistic) thoughts that such situations might engender.
There are areas of positive psychology, however, that have direct relevance concerning those
patient problems that cannot be solved. For example, the construct of
secondary control
(Roth-
baum, Weisz, & Snyder, 1982)—which refers to an enhanced sense of personal control over
uncontrollable events by virtue of exercising control over one's reactions to such events—is one
that has been of interest to positive psychologists by virtue of its association with positive
outcomes in the face of adverse circumstances (see Thompson, 2002, for a review). Enhanced
secondary control over problematic situations may be achieved by numerous means, among
them the strategy of benefit-finding (Tennen & Affleck, 2002), the identification of a sense of
meaning (e.g., religious, existential, philosophical, etc.) to be derived from the situation (Thomp-
son, 2002), or a
radical acceptance
of the situation via the practice of mindfulness meditation
(Linehan, 1993). Although it also is possible that the CBT therapist might increase the patient's
sense of secondary control over problematic situations through the use of standard CBT cog-
nitive reframing techniques (e.g., by challenging catastrophic interpretations of the situation),
we believe the incorporation of the aforementioned secondary control techniques could be of
great potential value in CBT, especially for the subset of depressed patients who are legitimately
distressed by the occurrence of uncontrollable negative life events.
Optimism Training. Optimists are famously good at coping with adversity. As a result, in
addition to an array of positive mental health benefits, optimists have been shown to be at
reduced risk for developing depressive symptoms (Carver & Scheier, 2002). Optimists are es-
pecially likely to use problem-focused coping, and as noted previously, such coping strategies
are emphasized within CBT. When problem-focused coping is not a possibility, optimists are
apt to use strategies that enhance a sense of secondary control, such as acceptance, positive
reframing, or humor (Carver et al, 1993). In contrast, pessimists tend to cope with difficulties
through overt denial and disengagement from the goals with which such difficulties may be
interfering. Although Carver and Scheier (2002) have observed "trying to turn pessimists into
optimists seems an apt characterization of the main thrust" (p. 240) of
CBT,
it is worth noting
that Beck and colleagues have designed the CBT intervention with the goal of producing
realists,
not optimists (Beck et al., 1979). In fact, CBT protocol is replete with admonitions to the
therapist to attempt to induce in the patient a realistic (not optimistic) appraisal of his or her
circumstances.
Consequently, Martin Seligman (2002), in his program of
learned
optimism training, has
extended the CBT approach in a fashion more unabashedly aligned with the sensibilities of
positive psychology, that is, with the ultimate aim of turning both children and adults into
functional optimists (as opposed to realists). Likewise, Snyder's hope theory emphasizes the
clinical importance of enhancing the patient's optimism regarding his or her capacity to achieve
important goals and to generate plausible strategies for achieving them (Snyder, 2002). Psycho-
therapeutic interventions explicitly informed by hope theory have been evaluated in several
recent clinical trials, and have proven to be successful both in increasing hopeful thought and
166 CBT and Positive Psychology
in decreasing acute psychopathological symptoms (see Cheavens, Feldman, Woodward, & Sny-
der, this issue).
Meaning. It has been shown that endowing life events with a sense of meaning and purpose
may engender positive effects on both physical and mental health (reviewed in Baumeister &
Vohs,
2002). Of course, there are many potential levels of meaning for a given activity, and
some are deeper and more satisfying than others. Watson (2002) goes so far as to claim that
"few of the events in our lives truly are important in any objective, absolute sense. Nevertheless,
it is essential that we perceive these things to be important and as representing goals that are
well worth pursuing. In other words, although little of what we do in life really is important, it
is crucial that we do them, and that we see them as important" (p. 116). Within our own
extensive experience utilizing the CBT protocol, a large proportion of patients have been ob-
served spontaneously to introduce themes of meaning and purpose during the course of ther-
apy—a phenomenon that, when validated and encouraged by the therapist, appears to increase
the patient's motivation to engage in core CBT interventions. We note, however, that there is
no overt or explicit treatment of "meaning-making," per se, within CBT. In light of the afore-
mentioned discussion, we believe the protocol may be amenable to using the patient's own
meaning-generation proclivities.
Humor. In their seminal CBT treatment manual. Beck and colleagues (1979) briefiy describe
the use of humor in treatment, noting its potential utility as a means of distracting the patient
from negative feelings or gently challenging entrenched beliefs. In an infiuential recent CBT
manual (Beck, 1995), however, there is no mention of humor as a treatment element. None-
theless, there exists some empirical evidence that humor may act as a buffer against the expe-
rience of depression (e.g., Nezu, Nezu, & Blissett, 1988). If humor does indeed serve as such a
protective factor, it is reasonable to infer that CBT might be enhanced by attending more closely
to the process of increasing patients' capacities for humor. Although there exists little research
evidence to guide clinicians in selecting interventions that may enhance the patient's sense of
humor, it has been suggested that "the encouragement of fiexible thinking, of learning to gen-
erate multiple responses to singular stimuli, and lessening the fear of rejection for attempts at
being comical or provoking laughter could be good starting points for those investigators wishing
to enhance the humorous capacity of their subjects" (Lefcourt, 2002, p. 628-629). The culti-
vation of humor during treatment might make therapy a more enjoyable process, and perhaps
provide some patients with another potent coping mechanism to use outside of the therapy
session. Moreover, as noted previously, the effective use of humor may promote secondary
control over otherwise uncontrollable aversive circumstances.
Physical
Exercise.
Engaging in physical exercise to enhance psychological well-being is a
practice congruent with the positive psychological framework (e.g., Watson, 2002). In fact,
consistent with the claim that "exercise is medicine" (Elrick, 1996), James Blumenthal and
his colleagues have recently observed an acute antidepressant effect for regular aerobic exercise
equivalent in efficacy to that of SSRI medication in a controlled randomized clinical trial
(Blumenthal et al., 1999), and there is accumulating evidence that physical exercise may be a
potent and efficacious intervention for depression (Blumenthal & Gullette, 2002), albeit one
that has not yet been widely recognized as such by clinicians. Accordingly, we believe there is
considerable potential for augmenting the existing CBT protocol with the judicious assignment
of regular aerobic exercise as a form of patient "homework." We note, however, that consid-
erable research is warranted in order to clarify: (a) which subset of CBT patients would be
likely to derive the most (or least) benefit from aerobic exercise; (b) at what point during
treatment (early, middle, late?) to introduce the exercise; and (c) which among an array of
possible therapist interventions (e.g., psychoeducation, provision of a detailed exercise regi-
men, addressing negative beliefs about exercise, etc.) would be most helpful in motivating
patients to adhere to an exercise program.
Karwoski
et
al.
167
CONCLUDING
REMARKS
Innovation and experimentation are hallmarks of the scientific process, and these principles are
perhaps nowhere more evident than in the domain of clinical research. Indeed, a glance at a list
of designated empirically supported treatments for psychological disorders (Sanderson &
Woody, 1998) reveals a set of interventions that were developed only within the past few decades.
Nevertheless, the breathtaking pace of clinical innovation that characterized the 1960s and 1970s
appears to have slowed somewhat in recent years—a troublesome development that has led
some influential psychotherapy researchers to lament the field's increasing potential for stag-
nation (Foa & Kozak, 1997). In this context, we are inclined to view the positive psychology
movement, with its novel focus on identifying individual strengths and "building the best qual-
ities in life" (Seligman, 2002), as a very hopeful development—one that appears to carry con-
siderable promise for catalyzing innovations via the integration of positive psychology principles
with existing forms of clinical interventions. Accordingly, we have outlined numerous ways in
which the principles and methods of positive psychology might be successfully integrated with
CBT for depression. Our goal is that these positive psychology ideas will help future psycho-
therapy researchers in finding ways to enhance CBT's acute efficacies and long-term prophylactic
benefits.
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