On the Integration of Cognitive-Behavioral Therapy for Depression and Positive Psychology

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. With its emphasis on identifying and cultivating individual strengths, however, positive psychology appears to have considerable potential 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 The 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 increasing 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 depression 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 dysfunctional 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, & llardi, 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 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 antidepressant 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, fewer 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 particularly 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. …