Treating Anhedonia When CBT Fails: Using Positive Affect Treatment for Depression and Anxiety

Elizabeth Spencer

Do you have clients who don’t get well, and struggle with low mood and lack of interest in anything?  Most of my clients get better and some of them get better really quickly which is very gratifying as a clinician.  However, I am keenly aware that a small group of clients does not have good results from CBT, even with the addition of medicine or in-patient treatment.  It’s with these clients in mind that I look to research to help guide the next steps – I want whatever we try to be evidence-based.  These are clients who are suffering terribly, and CBT has failed them.  Treating Anhedonia with Positive Affect Treatment is a great option to consider.

I came across research about Anhedonia — a loss of pleasure or interest in activities – which was found to predict a greater risk factor for suicidality, being a treatment non-responder, and relapse following treatment. This sounds like the clients I am most concerned about.  Standard CBT treatment for depression includes behavioral activation, which works well for the majority but not all clients.  The research showed that adding Positive Affect Treatment (PAT) can result in better outcomes for clients who have anhedonia.

Fortunately, a new workbook for clinicians, “Positive Affect Treatment for Depression and Anxiety” by Craske et all, came out in 2022, and outlines, step-by-step, how clinicians can help increase reward sensitivity with PAT.  After diagnosis and psychoeducation, the treatment moves on to help the client take action steps toward feeling better, attending to the positive, building positivity, and finally relapse prevention.  There are specific skills that are taught in each section, with the research to back up why those particular skills were selected, which is very important to me because these are clients who do not have any extra energy to put into treatments that are untested.  Some of the skills are familiar to me from positive psychology and are skills I often teach my clients, like loving kindness and savoring the moment.  However, in my experience these clients often find these skills to be difficult or, alternately, want to brush the skills off as irrelevant to their suffering.  I am finding it is working well to have evidence to demonstrate that spending time practicing these skills is worth our time and attention.

Consider if you have any clients with anhedonia, then take a look at the research:

Treating Anhedonia with PAT could be a game-changer for our clients when CBT fails.

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