i

Positive Affect Treatment

for Depression and
Anxiety
ii

TREATMENTS T H AT W O R K

Editor-​In-​Chief

David H. Barlow, PhD

Scientific Advisory Board

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

iii

TRE ATMENTS T H AT W O R K

Positive Affect
Treatment
for Depression and
Anxiety

THERAPIST GUIDE

MICHELLE G. CRASKE
HALINA J. DOUR
MICHAEL TREANOR
ALICIA E. MEURET
iv

Oxford University Press is a department of the University of Oxford. It furthers

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Published in the United States of America by Oxford University Press
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Library of Congress Cataloging-in-Publication Data
Names: Craske, Michelle G., 1959- editor. | Dour, Halina J., editor. |
Treanor, Michael, editor.
Title: Positive affect treatment for depression and anxiety : therapist guide /
edited by Michelle G. Craske, Halina J. Dour, Michael Treanor, and Alicia E. Meuret.
Description: New York, NY : Oxford University Press, [2022] |
Includes bibliographical references and index.
Identifiers: LCCN 2022003281 (print) | LCCN 2022003282 (ebook) |
ISBN 9780197548523 (paperback) | ISBN 9780197548530 (epub) |
ISBN 9780197548554
Subjects: LCSH: Depression in adolescence—Treatment. |
Depression in children—Treatment. | Anxiety in adolescence—Treatment. |
Anxiety in children—Treatment.
Classification: LCC RJ506. D4 P67 2022 (print) | LCC RJ506. D4 (ebook) |
DDC 616.85/2700835—dc23/eng/20220217
LC record available at https://lccn.loc.gov/2022003281
LC ebook record available at https://lccn.loc.gov/2022003282
DOI: 10.1093/​med-​psych/​9780197548523.001.0001
9 8 7 6 5 4 3 2 1
Printed by Marquis, Canada
v

About TREATMENTS THAT WORK

Stunning developments in healthcare have taken place over the last sev-
eral years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into
question by research evidence as not only lacking benefit, but perhaps,
inducing harm (Barlow, 2010). Other strategies have been proven ef-
fective using the best current standards of evidence, resulting in broad-​
based recommendations to make these practices more available to the
public (McHugh & Barlow, 2010). Several recent developments are
behind this revolution. First, we have arrived at a much deeper un-
derstanding of pathology, both psychological and physical, which has
led to the development of new, more precisely targeted interventions.
Second, our research methodologies have improved substantially, such
that we have reduced threats to internal and external validity, making
the outcomes more directly applicable to clinical situations. Third,
governments around the world and healthcare systems and policymakers
have decided that the quality of care should improve, that it should be
evidence based, and that it is in the public’s interest to ensure that this
happens (Barlow, 2004; Institute of Medicine, 2001, 2015; McHugh &
Barlow, 2010).

Of course, the major stumbling block for clinicians everywhere is

the accessibility of newly developed evidence-​ based psychological
interventions. Workshops and books can go only so far in acquainting
responsible and conscientious practitioners with the latest behavioral
health care practices and their applicability to individual patients. This
series, Treatments That Work™, is devoted to communicating these ex-
citing new interventions to clinicians on the frontlines of practice.

The manuals and workbooks in this series contain step-​by-​step detailed

procedures for assessing and treating specific problems and diagnoses.
But this series also goes beyond the books and manuals by providing
ancillary materials that will approximate the supervisory process in

v
vi

assisting practitioners in the implementation of these procedures in

their practice.

In our emerging healthcare system, the growing consensus is that

evidence-​based practice offers the most responsible course of action
for the mental health professional. All behavioral health care clinicians
deeply desire to provide the best possible care for their patients. In this
series, our aim is to close the dissemination and information gap and
make that possible.

A substantial number of individuals with depression or anxiety experi-

ence anhedonia, or loss of interest or joy in usual activities. Anhedonia
is a risk factor for poor prognosis and suicidality, and yet treatments to
date have been relatively ineffective for anhedonia. Based on advances in
behavioral and neuroscience, Positive Affect Treatment (PAT) was devel-
oped to specifically target areas of reward sensitivity that are believed to
contribute to anhedonia. These include the anticipation and motivation
for reward, the response to attainment of reward, and the learning of
associations between actions and reward outcomes.

The guide is intended to be used by clinicians who are familiar with

cognitive–​behavioral therapy (CBT) generally and with clinical presen-
tation of depression, anxiety, and anhedonia. Results show that PAT
not only improves positive mood state but also decreases depression and
anxiety. This therapist guide will be an indispensable resource for all
practitioners who wish to effectively and efficiently help individuals re-
gain interest and enjoyment in their usual activities while improving
their quality of life.

David H. Barlow, Editor-​in-​Chief

Treatments That Work™
Boston, Massachusetts

References

Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59,

869–​878.
Barlow, D. H. (2010). Negative effects from psychological treatments: A
perspective. American Psychologist, 65(2), 13–​20.

vi
vi

Institute of Medicine. (2001). Crossing the quality chasm: A new health

system for the 21st century. National Academy Press.
Institute of Medicine. (2015). Psychosocial interventions for mental and sub-
stance use disorders: A framework for establishing evidence-​based standards.
National Academies Press.
McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementa-
tion of evidence-​based psychological interventions: A review of current
efforts. American Psychologist, 65(2), 73–​84.

vii
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ix

Contents

Module 1: Psychoeducation

Chapter 1 Introductory Information for Therapists 3

Chapter 2 Behavioral Science and Neuroscience Identify
Targets for Treatment of Anhedonia 13
Chapter 3 General Treatment Format and Guiding
Therapy Principles 25
Chapter 4 Psychoeducation 37

Module 2: Treatment Skill Sets

Chapter 5 Actions Toward Feeling Better 55

Chapter 6 Attending to the Positive 83
Chapter 7 Building Positivity 111

Module 3: Treatment Gains and Relapse Prevention

Chapter 8 Continuing the Journey After Treatment 145

Appendix: Client Exercises 153

Recommended Readings 175
References 177
About the Authors 193

ix
x
1

MODULE 1

Psychoeducation
2
3

CHAPTER 1
Introductory Information
for Therapists

(Corresponds to c­ hapter 1 of the workbook)

Background Information and Purpose of This Program 3

What Is Anhedonia? 4
Existing Treatments Are Inadequate for Anhedonia 5
Efficacy of PAT 6
Who Will Benefit from PAT? 9
What If Other Emotional Problems Are Present? 9
Role of Medication 10
Who Should Administer the Program? 11
Benefits of Using the Client Workbook 11

Background Information and Purpose of This Program

Anhedonia is a symptom cluster involving loss of interest or joy in usual

activities. Typical client statements that are indicative of anhedonia in-
clude “I just don’t find anything to be enjoyable,” “Things that I used
to enjoy seem like a chore,” or “What is the point of trying? I never
feel good.” Anhedonia is a transdiagnostic symptom that characterizes
many individuals suffering from depression, as well as some types of
anxiety, psychosis, and substance use. To date, anhedonia has been rel-
atively unresponsive to psychological and pharmacological treatments.
Yet, anhedonia is a significant marker of a poor long-​term course for
depression, as well as a poor response to existing treatments, both psy-
chological and pharmacological. Furthermore, anhedonia is a robust
4

predictor of suicidality, including suicide attempts, above and beyond

other symptoms. Thus, anhedonia represents a significant marker of
psychopathology and of risk.

Part of the reason why existing psychological and pharmacological

treatments have had limited effect on anhedonia is their lack of focus on
its underlying mechanisms. Advances in behavioral science and neuro-
science, including work from our own laboratories, have found specific
mechanisms that may contribute to anhedonia. These mechanisms con-
verge on deficits in reward responsiveness—​specifically, deficits in the
anticipation of reward or motivation to work for reward, deficits in the
savoring or appreciation of reward, and deficits in the learning of re-
ward. The majority of treatments to date have focused almost exclusively
on decreasing the negative valence associated with the defensive system
rather than addressing deficits in the reward system (Craske et al., 2016).
We saw a need for a new treatment approach that specifically targets
deficits in the reward system, which we call Positive Affect Treatment
(PAT; Craske et al., 2019). This therapist guide, which accompanies
the PAT workbook for clients, describes the underlying principles and
procedures of PAT.

What Is Anhedonia?

Lack of enjoyment in and lack of desire for usual activities are the core
features of anhedonia (American Psychiatric Association, 2016). Low
levels of positive emotions are key to anhedonia. A substantial number
of individuals with depression are estimated to have clinically signifi-
cant anhedonia as defined by cutoffs on scales that measure enjoyment
of social and physical pleasure (Pelizza & Ferrari, 2009). However, an-
hedonia is not limited to depression. A body of evidence contradicts
earlier models that linked positive affect almost exclusively to depression
relative to anxiety (Brown et al., 1998; Clark & Watson, 1991). In fact,
effect sizes for cross-​sectional and longitudinal relationships between
positive affect and anxiety are significant and indistinguishable from
corresponding effect sizes for positive affect and depression (Khazanov
& Ruscio, 2016; Kotov et al., 2010). Moreover, hedonic impairments
have been observed in social anxiety disorder (Kashdan et al., 2011),
posttraumatic stress disorder (Hopper et al., 2008; Litz et al., 2000),

4
5

and generalized anxiety disorder (Srivastava et al., 2003), including

youth samples (Morris et al., 2015).

Anhedonia is a major marker of psychopathology. For example, anhe-

donia prospectively predicts both depression and anxiety, even when
controlling for baseline symptoms (Kendall et al., 2015; Khazanov
& Ruscio, 2016). Once disorders emerge, anhedonia is a robust pre-
dictor of a poorer longitudinal course of major depression (Morris et al.,
2009). Further, anhedonia predicts poor psychosocial functioning after
improvements in depressed mood (Vinckier et al., 2017) and recurrence
of depression (Wichers et al., 2010). Moreover, anhedonia is a substan-
tial predictor of suicidal ideation and attempt (Ducasse et al., 2018;
Spijker et al., 2010; Winer et al., 2014). In over 2500 clients with mood
disorders, those with anhedonia had a 1.4-​fold higher risk of suicidal
ideation in the next three years (Ducasse et al., 2021). The predictive
effects on suicidal ideation or attempt persist when controlling for other
cognitive and affective symptoms of depression (Ballard et al., 2017;
Fawcett et al., 1990), as well as other risk factors such as history of sui-
cide attempts, childhood trauma, marital status, sex, and age (Ducasse
et al., 2021). Finally, anhedonia statistically accounts for the relation
between depression and suicidality (Zielinski et al., 2017).

Existing Treatments Are Inadequate for Anhedonia

Clients with depression often view the restoration of positive mood

as their primary treatment goal, over reducing negative symptoms
(Demyttenaere et al., 2015). Yet, extant treatments are inadequate to
address positive mood. Specifically, standard medication treatments
have mixed effects and may even worsen positive emotions or responses
to rewarding stimuli (Landén et al., 2005; McCabe et al., 2010;
Nierenberg et al., 1999; Price et al., 2009), although newer pharma-
cological approaches such as kappa-​opioid antagonism and ketamine
are showing promising effects (Ballard et al., 2017; Pizzagalli et al.,
2020; Thomas et al., 2018). Evidence-​based psychotherapies (primarily
cognitive–​behavioral therapy [CBT] and mindfulness-​based cognitive
therapy) have limited effects on positive affect (Boumparis et al., 2016).
For example, in a reanalysis of DeRubeis et al. (2005), cognitive therapy
and antidepressant medication normalized elevations in negative affect

5
6

but had little effect on positive affect measured using the Positive and
Negative Affect Schedule (PANAS) (Watson et al., 1988). Even behav-
ioral activation therapy, which aims to increase positive affect through
response-​contingent positive reinforcement from rewarding activities
(Martell et al., 2010), has limited effects on positive affect or anhedonia
in the few studies in which such effects have been reported (Dichter
et al., 2009; Moore et al., 2013). This is perhaps not surprising since
little attention has been given to how to conduct behavioral activation
in a manner that maximizes rewarding, positive emotional experiences
(Dunn, 2012; Forbes, 2020). We proposed that treatment effects will
be bolstered by targeting processes thought to underlie anhedonia, in-
cluding deficits in reward responsiveness. Our Positive Affect Treatment
(Craske et al., 2016, 2019) is designed specifically to target deficits in
reward responsiveness for symptoms of anhedonia.

Efficacy of PAT

In our randomized controlled trial for clients with clinically significant

and impairing anxiety or depression, we compared PAT to a cognitive-​
behaviorally based intervention called Negative Affect Treatment [NAT].
NAT included exposure to distressing and avoided situations, cogni-
tive restructuring to reduce overestimates of threat, catastrophizing and
attributions of self-​blame, and arousal regulation through respiratory
training. PAT included behavioral activation to rewarding experiences
augmented by savoring the moment; cognitive tools for increasing at-
tention to positive stimuli; and cultivation of positive emotions through
mood-​boosting exercises of appreciative joy, gratitude, generosity, and
loving-​kindness. The treatment was implemented over 15 individual
sessions. Clients were randomized to either treatment condition, and
assessments were completed at baseline, throughout treatment, at
posttreatment, and at six months follow-up.

PAT resulted in greater improvements in positive affect than NAT

(Craske et al., 2019). Figure 1.1A represents the change in positive af-
fect, measured using the Positive Affect Scale of the PANAS, for PAT
and NAT. Clients had very low positive affect at treatment outset (below
the 15th percentile of population norms), but values for those in the
PAT group reached the population norm at the end of treatment and
following treatment. This is the first demonstration of a psychological

6
7

Figure 1.1
Changes in positive affect (A) and negative affect (B), measured using the PANAS, in
Positive Affect Treatment (PAT) and Negative Affect Treatment (NAT).
Copyright © 2019, American Psychological Association.

treatment that normalizes positive affect in clients with depression or

anxiety. Figure 1.1B also shows that PAT was more effective than NAT
in reducing negative affect.

Participants in PAT also reported superior reductions in depression,

anxiety, stress, and suicidality at the six-​month follow-​up. As shown
in Figure 1.2, depression, anxiety, and stress were very high at base-
line and decreased into a normal (non-​clinical) range over the course

7
8

Figure 1.2
Changes in depression (A), anxiety (B), and stress (C), measured using the Depression,
Anxiety, and Stress Scale, in PAT and NAT.
Copyright © 2019, American Psychological Association.

8
9

of treatment and follow-​up (six months after treatment). We have

replicated these initial effects in a second randomized controlled trial
(publication forthcoming).

Who Will Benefit from PAT?

As noted, PAT was developed specifically to address deficits or

dysregulation in reward responsiveness that characterize anhedonia,
or the loss of interest or joy in usual activities. Our PAT trial was
conducted with individuals who presented with levels of depression
and anxiety and anhedonia that were above clinical severity cutoffs, and
the majority were diagnosed with either an anxiety disorder or a major
depressive disorder, or both. Nonetheless, we would also expect the
program to be useful in treating symptoms of depression and anxiety
in clients who do not meet the full diagnostic clinical criteria, as well as
individuals who score subthreshold on severity criteria, but are at risk
for full disorder status.

Aside from depression and anxiety, anhedonia is characteristic of

individuals with substance use, trauma, eating disorders, and schizo-
phrenia. To date, PAT has been evaluated only in individuals who pre-
sent with depression or anxiety and has not been tested in individuals
with other disorders. Nonetheless, we expect that it will be helpful
when tailored to the needs of individuals with other disorders as well.

During the initial client assessment, it can be helpful to complete

Exercise 2.1: Treatment Fit Assessment and Exercise 2.2: Treatment
Timing Assessment, which can be found in ­chapter 2 of the client
workbook (on page 16 and 17) and also in the appendix at the end of
this therapist guide. You may photocopy these assessments or down-
load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT).

What If Other Emotional Problems Are Present?

The evidence strongly suggests high levels of overlap across the var-
ious anxiety disorders and mood disorders both at the diagnostic level
and the symptomatic level. This is why current and lifetime diagnostic

9
10

comorbidity are observed across the anxiety and mood disorders (e.g.,
Kessler et al., 2005). It is very common for individuals with one anx-
iety disorder to have another anxiety disorder or a mood disorder, and
similarly for individuals with a principal mood disorder to also have an
anxiety disorder. The presence of multiple disorders, however, does not
preclude the use of PAT. In fact, PAT was developed specifically to target
the underlying dimension of anhedonia that cuts across distinct diag-
nostic entities of specific anxiety disorders and mood disorders. Notably,
the majority of study participants suffered from comorbid anxiety and
mood disorders.

Role of Medication

Clients often seek psychological treatment for emotional problems, in-

cluding anhedonia, while already taking psychotropic medications. Some
clients present to our clinics having been prescribed low doses of high-​
potency benzodiazepines such as alprazolam (Xanax) or clonazepam
(Klonopin), or antidepressants including selective serotonin reuptake
inhibitors (SSRIs) such as paroxetine (Paxil) or fluoxetine (Prozac), ser-
otonin–​norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine
(Effexor), or tricyclic antidepressants such as clomipramine. The effects
of combining medications with PAT are not yet understood and await
further investigation. Thus, we do not recommend that clients discon-
tinue medications before initiating PAT, rather they should continue
on a stable medication dose. Unless clinically necessary, we usually dis-
courage clients from increasing dosages of medication or beginning
new medications during treatment. This is because medication changes
can interfere with therapeutic strategies and with evaluation of the
medication’s effectiveness. This can become confusing for the therapist
and frustrating for the client and may ultimately lead to poorer treat-
ment outcomes.

Certain psychotropic medications have anhedonic side effects (Landén

et al., 2005; McCabe et al., 2010; Price et al., 2009). Thus, it might be
advisable for clients who are currently taking psychotropic medications
to discuss with their prescriber the possibility that their anhedonic
symptoms are related to medications.

10
1

Who Should Administer the Program?

The treatment concepts and techniques are presented in detail in the cor-
responding client workbook so that the mental health professional can su-
pervise its implementation. Nonetheless, we do recommend that therapists
are familiar with basic principles of cognitive–​behavioral interventions.
The therapist should also have a good understanding of the principles un-
derlying the treatment procedures in the client workbook. This will allow
the therapist to adapt the material to suit the needs of each client and to
overcome difficulties and barriers in the treatment should they arise. We
also recommend that the therapist become familiar with the nature of an-
hedonia using some of the basic information presented in this therapist
guide along with the recommended readings that we provide.

Benefits of Using the Client Workbook

While it may appear that clients have a good understanding of the mate-
rial that is presented by the therapist during session, it is not uncommon
for them to misremember or forget important points. One of the
greatest benefits of a client workbook is that it provides a review of treat-
ment concepts, explanations, and instructions that the client can read
between sessions. It also is an immediate reference that clients can use
to help guide themselves when they experience anhedonic symptoms.
This can be important because they can apply the learning process as
the need is emerging, which may in turn lead to greater understanding
of the treatment concepts and better appreciation of how to apply these
procedures effectively.

Having the client workbook available allows clients to move at their own
pace. Some may wish to move more quickly through the program by
scheduling more frequent sessions, while others may choose to move
more slowly due to conflicting demands such as work or travel. Having
the client workbook available between scheduled sessions for review or
rereading can be quite beneficial. Having the workbook also ensures that
clients have a ready resource to refer back to after treatment ends. Clients
will likely experience times when they need to revisit treatment content.
The workbook is an essential resource to remind clients of what they
learned and what they can continue to practice. Further, if the workbook
is insufficient, they can request booster sessions with their therapist.

11
12
13

Behavioral Science and

Neuroscience Identify
CHAPTER 2
Targets for Treatment
of Anhedonia

(Corresponds to c­ hapters 1 and 2 of client workbook)

Targets for Treating Anhedonia: Reward Processes 13

Skills to Build Wanting, Liking, and Learning Reward 16
Labeling Emotions 18
Actions Toward Feeling Better 18
Attending to the Positive 21
Building Positivity 22

Targets for Treating Anhedonia: Reward Processes

It has long been recognized that at least two core systems regulate thoughts
and behaviors or actions. An approach or appetitive system that motivates
actions toward goals and rewards is linked with positive emotions such
as enthusiasm and pride. A withdrawal or defensive system that motivates
avoidance of aversive outcomes or punishments is linked with negative
emotions such as fear and sadness (Lang & Bradley, 2013; Lang & Davis,
2006; Shankman & Klein, 2003). Our decision-​making and survival de-
pend on striking a balance between the defensive system to protect our-
selves from dangers and the appetitive system to achieve the nutrients and
nurturing to survive. Should we enter an unfamiliar and thereby poten-
tially risky situation or avoid it at the cost of losing a potential social or
monetary reward? We need the defensive system to remain safe and the
appetitive system to accomplish our goals and feel satisfied and happy.

Anxiety and depression have long been understood to involve excesses

in the defensive system, or an elevated threat responsivity. This would
14

explain features such as increased hypothalamic–​ pituitary–​

adrenal
(HPA) axis and physiological stress responses, increased bias to attend
to threat and to interpret ambiguous situations as threatening, and
increased tendencies to avoid potentially threatening situations. More
recently, the role of deficits in the appetitive reward system, or lowered
reward sensitivity, has been recognized. These deficits explain features
such as lowered physiological arousal to and self-​reported interest in the
anticipation of reward or the receipt of reward, lowered sustained atten-
tion to positive stimuli, and lowered effort to gain reward.

While researchers emphasize different parts of the reward system,

there is some convergence upon three main components (Figure 2.1;
Der-​Avakian & Markou, 2012; Thomsen et al., 2015):

■ Anticipation or motivation for reward (wanting) is interest in future

rewarding experiences and the effort expended to receive reward.
■ Responsivity to attainment of reward (liking) refers to the pleasure
or hedonic impact of reward, noticing when something rewarding
happens and appreciating it.

Figure 2.1
Parts of the reward system and associated deficits of anhedonia.
Clipart sourced from Microsoft PowerPoint.

14
15

■ Learning of reward (learning) involves Pavlovian or instrumental

associations and predictions about future rewards based on past
experiences (i.e., learning what actions lead to rewards and what
stimuli are rewarding).

In the client workbook, these three components are shown in Figure 1.1
in ­chapter 1.

The brain’s reward circuitry encompasses regions of the basal ganglia,

notably the ventral and dorsal striatum and the prefrontal cortex, partic-
ularly the orbitofrontal cortex (Berridge & Kringelbach, 2015; Mahler
et al., 2007; Peters & Büchel, 2010). Functional neuroimaging studies
report consistent activation of this circuitry during the initial response,
anticipation of reward, and learning of reward. There is compelling
evidence for strong links between low positive mood and reward hy-
posensitivity across the three components (McFarland & Klein, 2009;
Pizzagalli et al., 2008; Thomsen et al., 2015).

Specifically, anhedonic symptoms of loss of pleasure or interest are as-

sociated with deficits in ventral striatum responsivity to anticipation of
reward (Greenberg et al., 2015; Stoy et al., 2012; Ubl et al., 2015). At
the behavioral level, the effort expended to obtain rewards correlates
negatively with anhedonia (Treadway et al., 2012; Yang et al., 2014).
Together, evidence suggests that anhedonia is associated with neural
and behavioral deficits in the anticipation and motivation of reward, or
deficits in wanting of reward.

In terms of reward attainment, ventral striatum hypoactivity to posi-

tive stimuli is particularly related to anhedonic symptoms relative to
depression symptoms more broadly (Chung & Barch, 2015; Pizzagalli
et al., 2009; Wacker et al., 2009). Similarly, reports of weaker positive
emotions to positive stimuli are more strongly related to symptoms
of anhedonia than symptoms of depression after excluding anhe-
donia (Clepce et al., 2010). Furthermore, anhedonia is associated with
reduced cardiac acceleration while viewing pleasant pictorial stimuli
or imagining pleasant emotional scripts (Fiorito & Simons, 1994;
Fitzgibbons & Simons, 1992). Together, evidence suggests that anhe-
donia is associated with deficits in neural, subjective, and physiological
responses when reward is attained, or deficits in liking of reward.

For reward learning, blunted ventral striatal responses to instrumental

conditioning tasks correlate with anhedonic symptoms (Gradin et al.,
15
16

2011; Whitton et al., 2015). Also, impairments in a response bias to

stimuli that are frequently rewarded correlate with anhedonia and pre-
dict anhedonic symptoms in the future (Pizzagalli et al., 2005, 2008;
Vrieze et al., 2013). Overall, the evidence suggests that anhedonia is
associated with deficits in neural and behavioral indicators of learning
what is rewarding or how to obtain rewarding outcomes.

In the Positive Affect Treatment (PAT) client workbook, we state:

For example, it can be hard for someone with anhedonia to look

forward to positive events, feel good when there is a positive event,
and know how to make themselves feel more positive. It is as if the
mood system that regulates positive emotions is not working so well.

For these reasons, PAT was designed to specifically target the anticipa-
tion and motivation for reward, the initial response to reward attain-
ment, and the learning of reward. Every aspect of the PAT program is
designed to improve reward responsiveness. As you will see, clients often
feel drawn to focus on the negative parts of their experience, to dwell
on the worst, and to analyze the most negative parts of their lives to try
to understand their reasons, or to fix them. In contrast, PAT takes the
approach of focusing on building capacity to look forward to, attend
to, enjoy and savor, and learn about positive and rewarding experiences.
The premise is that by building capacity for reward, not only will re-
warding experiences be felt more strongly (rather than being dismissed)
but negative experiences (internal or external) will also become less pre-
dominant. We further present to clients that building the capacity for
positivity will enable them to be better able to manage the negative
experiences of life.

Skills to Build Wanting, Liking, and Learning Reward

In the psychoeducation module, we begin by providing the science

and theory behind each PAT skill. Guided by behavioral science and
affective neuroscience, we developed PAT to specifically address the
major components of reward responsiveness that have shown to be
dysregulated as a function of anhedonia (Craske et al., 2016). The
components of PAT and their primary reward system targets are
shown in Figure 2.2, which includes the corresponding chapters in
the client workbook.
16
17

Figure 2.2
Overview of skills in the modules and chapters.
Clipart sourced from Microsoft PowerPoint.

17
18

Labeling Emotions

Following psychoeducation and the description of cognitive, behav-

ioral, and physiological components of mood cycles, Module 1 teaches
the skill of emotion labeling for positive emotions. Individuals who are
depressed can have difficulties identifying or labeling their emotions
(alexithymia) (Honkalampi et al., 2001). Since individuals with an-
hedonia experience fewer positive emotional states overall, their rep-
ertoire for describing positive emotions is typically limited. Building
this repertoire requires discriminating among different intensities and
types of positive emotions (e.g., joy, thrill, contentment), and such
discrimination facilitates attention to and encoding of internal states
(e.g., feelings or thoughts) associated with each positive emotion.
Training clients to attend to internal states associated with hedonic
feelings offsets the deficits in sustained attention to positive stimuli
that characterizes depression and anhedonia (Shane & Peterson,
2007), with a preference to attend to negative stimuli (Koster et al.,
2005). Hence, the process of labeling positive emotions is likely to
enhance attention to positive experiences, which will increase the at-
tainment of reward.

Actions Toward Feeling Better

Following psychoeducation about the mood cycle and labeling of

emotions, Module 2 presents the three treatment skill sets in PAT.
Chapter 5 instructs clients how to plan and practice positive activi-
ties by Savoring the Moment through memory specificity training, to
enhance hedonic impact. The first part draws heavily from original
models of behavioral activation therapy that was designed to increase
engagement in rewarding experiences (Lewinsohn & Libet, 1972).
Behavioral activation involves designing and practicing daily activities
that are inherently pleasurable, those that provide a sense of accom-
plishment or mastery, or those that are consistent with valued actions.
The Designing Positive Activities skill targets the anticipation and moti-
vation for reward, or wanting, and the Practicing Positive Activities skill
targets response to attainment of reward, or liking. Detailed labeling of
the positive emotions experienced during the activities facilitates the

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attainment or appreciation of reward, or liking. Changes in mood are

closely monitored from before to after each activity to reinforce the pos-
itive mood-​inducing effects; doing so targets reward learning (i.e., in-
strumental learning by which engaging in a specific activity increases
positive mood or overall mood).

Equally important, if not more so, is the subsequent memory speci-

ficity training to target the attainment or savoring of reward (we call it
Savoring the Moment). Savoring the Moment represents a departure from
behavioral activation therapy. Such memory enhancement is essential
because of a number of features that are characteristic of depression and
that impede the savoring and learning of reward. These features are:

■ Impoverished positive mental imagery. Individuals with depression

have more negative mental imagery and deficits in generating vivid
past-​oriented (Werner-​Seidler & Moulds, 2011) or future-​oriented
(Stöber, 2000) positive mental images and prospections (Yang et al.,
2018) than do individuals without depression.
■ Bias for a third-​person perspective (vs. a first-​person one), which
leads to less positive emotionality (Holmes et al., 2008a; Mcisaac &
Eich, 2002).
■ Overly general autobiographical memory (Holmes et al., 2016), or
failure to generate specific memories that take place within the span
of a single event or single day (Williams et al., 2007), which is a
predictor of the onset of depression and poorer course of depression
(Barry et al., 2019; Brewin, 2006).
■ A deficiency in positive self-​representations (Brewin, 2006).

For these reasons, individuals with depression undervalue posi-

tive memories, as shown by decreased willingness to spend money
for the opportunity to recall positive memories (Speer et al., 2014).
Devaluation of positive memories likely contributes to ineffective-
ness of standard behavioral activation therapy in terms of anhedonia
outcomes, since the standard approach involves only guidance to engage
in pleasurable activities and does not address memories for such activi-
ties. To target these abnormalities, our memory specificity training (for
Savoring the Moment) involves visualizing assigned activities, including
specific sensations, thoughts, emotions, and situational details, through
first-​
person perspective and present tense. Our approach resembles

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other memory specificity interventions for emotional disorders that

have led to short-​term significant improvements in overly negative ge-
neral memory, depression, hopelessness, problem-​solving, anticipatory
pleasure, and behavioral intention to engage in activities (Barry et al.,
2019; Hallford et al., 2020a, 2020b; McMakin et al., 2011; Pictet et al.,
2016). However, in PAT, the primary goal of Savoring the Moment is
to enhance the hedonic impact of reward and to improve the skill of
appreciating and liking a rewarding event.

During memory specificity training for Savoring the Moment,

participants are guided to close their eyes, visualize, and recount
in present tense the moment-​ to-​
moment details (surroundings,
emotions, physical sensation, and thoughts), while focusing on the
most positive experiences within the experienced activity. Through
being repeatedly guided to attend to their physical sensations,
thoughts, behaviors, and positive mood, the recounting is designed
to deepen and savor the positive aspects of the experience. Other
processes are likely taking place through Savoring the Moment. For
example, the guided memory recounting involves shifting attention
away from negative portions and toward positive portions of the be-
havioral experience. This is serving as a type of attentional control
(shifting attention from one aspect of a situation to another). Such
attentional control has been shown to be effective as a form of emo-
tion regulation (Gross, 1998).

Additionally, memory specificity training involves sustained attention

to positive stimuli, which itself has been shown to lead to subsequent
preferences for positive stimuli, albeit in nonclinical samples (Wadlinger
& Isaacowitz, 2008). Increased preference for positive material is pos-
ited to in turn decrease interest in negative information (Wadlinger &
Isaacowitz, 2011). Furthermore, training positive attentional preferences
may enhance attentional vigilance for and orienting toward positive in-
formation that eventually shifts more elaborate attention mechanisms
in the direction of positive meanings. This facilitates encoding of posi-
tive information in daily experiences. Consequently, training attention
to positive features of experience is likely to increase positive affect,
perhaps via attentional processes that reinforce positive affect, and is

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posited to increase tendencies to approach rewards in the environment

(Wadlinger & Isaacowitz, 2011).

Attending to the Positive

Chapter 6 comprises a set of cognitive training skills for attending to pos-

itive stimuli. Unlike cognitive therapy for depression, which challenges
negative cognitions, PAT cognitive techniques aim to identify and savor
positive aspects of experience (liking), take responsibility for positive
outcomes (liking and learning), and imagine and appreciate future pos-
itive events (wanting). Hence, the PAT cognitive skill set does not ad-
dress negative thoughts, or errors in thinking that may have contributed
to negative assumptions and beliefs. Instead, the discussion is focused
on attending to positive features of experiences in the past, present, and
future. The cognitive skills primarily involve attention training without
direct attempts to develop alternative appraisals. Targeting attention is
expected to impact mood for the same reasons specified earlier (i.e.,
increases in positive affect, increases in preference for positive stimuli,
decreased interest in negative stimuli, and eventual shift toward more
positive meanings). Hence, even though there is little direct attempt
to change negative appraisals, underlying meanings and appraisals may
shift in a more positive direction. One exception is the skill of Taking
Ownership where clients are asked to consider ways in which they may
have contributed to a positive outcome, which in turn is likely to more
directly influence self-​appraisals.

The first cognitive training skill, Finding the Silver Linings, trains clients
to recognize and appreciate the positive features in everyday situations,
even situations that are negative. The repeated practice of identifying
multiple positive elements in everyday situations is presumed to en-
hance preference for, attentional vigilance to, and encoding of positive
information (Wadlinger & Isaacowitz, 2011).

The second skill, Taking Ownership, involves repeated practice of

identifying one’s own behavioral contributions to positive outcomes in
daily lives (learning) and to savor positive emotions of pride, mastery,

21
2

and excitement (wanting). Accomplishments can be read out loud in

front of a mirror to deepen the experience of receipt of reward. Taking
Ownership counters the depressive attributional bias to attribute positive
outcomes to external factors and is consistent with experimental evidence
for training toward a positive attributional bias (Peters et al., 2011).

The third skill, Imagining the Positive, is based on evidence in favor

of enhanced positive mood and improvements in interpretation
bias effects following repeated practice of imagining positive events
(Holmes et al., 2006, 2008b; Pictet et al., 2011). Imagining the Positive
was drawn from experimental protocols by Holmes and colleagues in
which participants repeatedly imagine positive outcomes to ambiguous
scenarios, as well as the work of others showing the deficits in genera-
tion of positive images for the future as a function of depressed mood
(MacLeod et al., 1993). In PAT, clients are guided to repeatedly im-
agine as many positive aspects as possible about an upcoming event,
including positive emotions such as excitement, joy, and curiosity, in
order to facilitate the wanting of reward.

Building Positivity

Chapter 7 presents a set of experiential skills designed to cultivate and

savor positive experiences that are intended to increase the liking of re-
ward. These skills include daily practices of the mental act of giving
through the practice of Loving-​Kindness (i.e., mentally sending thoughts
of happiness, health, peace, and freedom from suffering) and the phys-
ical act of giving through Generosity (i.e., engaging in an act of gener-
osity at least once daily without expecting return). They also involve
daily practices of the mental act of wishing continued fortune to others
through Appreciative Joy (i.e., wishing continued health, joy, and for-
tune) and of generating a sense of gratefulness through the practice of
Gratitude. Mood is rated before and after each exercise to evaluate the
mood-​inducing effects; doing so also targets the learning of reward (i.e.,
by engaging in this practice, mood improves).

Much of the content of this chapter was adapted from loving-​kind-

ness, generosity, appreciative joy, and gratitude practices developed at

22
23

the UCLA Mindful Awareness Research Center. We modified these

techniques so that the exercises focused only on positive aspects.

The skill of Loving-​Kindness has been described as an act of training

one’s emotional experience toward warmth and tenderness (Garland
et al., 2010). It is a skill that encourages the practitioner to focus aware-
ness on loving and kind concern of other living beings, oneself, and
the world (Hofmann et al., 2011). It is thought to be particularly
helpful for alleviating strong negative emotions such as hostility, anger,
self-​criticism, and shame through increases in empathy and positive
mood. Practices in Loving-​Kindness, even brief ones (Hutcherson et al.,
2008), have been shown to lead to increases in positivity toward self
and others and improvements in positive affect and personal resources
(e.g., personal relationship with others, physical health, self-​acceptance,
satisfaction) (Fredrickson et al., 2008). Preliminary evidence from proof-​
of-​concept clinical trials in individuals with schizophrenia (Mayhew &
Gilbert, 2008), posttraumatic stress disorder (Kearney et al., 2013), and
dysthymia (Hofmann et al., 2015) show increases in positive emotions
and an improved sense of self and others.

Acts of Generosity similarly have been linked to improvements in

positive mood (Nelson et al., 2016; Rowland & Curry, 2019). In
a reciprocal cycle, prosocial behaviors have been shown to increase
positive mood, which in turn increases prosocial behaviors (Snippe
et al., 2018). Furthermore, there is some evidence that the pos-
itive mood effects of prosocial behavior toward others are greatest
for those with depression, at least in adolescent samples (Schacter &
Margolin, 2019).

Cultivating Gratitude (by creating gratitude lists, gratitude contempla-

tion, or the behavioral expression of gratitude) leads to state changes
in positive mood, greater resourcefulness, and general well-​being (Froh
et al., 2009; Geraghty et al., 2010a, 2010b; Wood et al., 2010), albeit
in nonclinical samples. It is speculated that practicing Gratitude leads to
increased value of help from others (Maltby et al., 2008; Wood et al.,
2010), which leads to seeking more social support and strengthening
social bonds (Wood et al., 2008a). This “broaden and build” ap-
proach (Fredrickson, 2001) is thought to add to resiliency (Emmons &
McCullough, 2003).

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Appreciative Joy is a practice that involves feeling happiness for people

with success, good fortune, or happiness. Similar to practices of Loving-​
Kindness, Appreciative Joy has been associated with increases in positive
mood, positive thinking, interpersonal relations, empathic accuracy,
and improvements in psychological distress, although studies have lim-
itations (Shonin et al., 2015; Zeng et al., 2015). In one small study,
Appreciative Joy alone was found to increase positive mood in a healthy
sample (Zeng et al., 2019).

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25

General Treatment
CHAPTER 3 Format and Guiding
Therapy Principles

(Corresponds to c­ hapter 3 of client workbook)

Treatment Module and Schedule Overview 25

Module Summaries 26
Treatment Schedule 28
Treatment Basics and Exercise Forms 30
Program Adaptations 33
Client Commitment 35

Treatment Module and Schedule Overview

As mentioned in ­chapter 2, the Positive Affect Treatment (PAT) was

developed with theory, science, and clinical experience in mind. PAT
follows the rationale, components, and structure of traditional evidence-​
based therapies. At the same time, it encourages tailoring to the clients’
needs and priorities (see p. 32 later in this chapter). Flexibility is of
the essence as individuals with anhedonia (low positive affect) are
lacking the prerequisites for cognitive–​behavioral therapy to be suc-
cessful: motivation! The very nature of anhedonia is lack of drive, moti-
vation, and ability to enjoy or appreciate positive change, at least at first.
Those deficits need to be carefully considered, and treatment should be
adjusted accordingly to ensure maximum client benefits.

The early part of treatment focuses on actions and behavioral change.

Research suggests that early behavioral change is associated with
26

early-​
in-​
treatment therapeutic gains. In PAT, behavioral change is
designed to increase reward sensitivity and access to rewards in the
environment that in turn reinforces further behavioral change. Those
gains are essential to motivation and drive. Behavioral gains are then
complemented by cognitive changes and positive practices designed to
build reward capacity even further. Behavioral changes are not the focus
of the second half of treatment but should continue nonetheless as the
new cognitive and positive practice skills are targeted.

As is standard in evidence-​based psychotherapy, everyday practice is a

fundamental ingredient of this therapy.

Module Summaries

Module 1: Psychoeducation

■ Duration: One or two sessions

■ Corresponding therapist guide chapter: 1, 2, 3, 4
■ Corresponding client workbook chapters: 1, 2, 3, 4

This module was designed to provide psychoeducation on the nature

of anhedonia, therapy expectations and structure, and the concepts of
the mood cycle. Clients are educated about the nature of anhedonia,
the consequences of anhedonia, associated psychiatric conditions,
and the efficacy of PAT. They are also presented with the basic prin-
ciples of the treatment format and expectations, and they are given
an opportunity to determine their readiness and need for treatment.
At this point in treatment, the therapist should consider treatment
tailoring (­chapter 3). Clients are then introduced to the interrelation-
ship of thoughts, behaviors, and physical sensations or feelings (the
mood cycle) and how they are targeted in PAT. They will also learn
what an upward spiral is, as opposed to a downward spiral, and how
it influences how we think, act, and feel. Clients practice their own
example of a positive mood cycle.

Next, clients are introduced to different types of positive emotions

through labeling (using the labeling emotions exercise). Clients learn
that identifying and labeling the different positive emotions requires

26
27

careful attention and increases positive affect. They are given the oppor-
tunity to review and individualize a positive label chart.

Module 2: Treatment Skill Sets: Actions Toward Feeling Better

■ Duration: Six sessions

■ Corresponding therapist guide chapter: 5
■ Corresponding client workbook chapter: 5

The key concepts in this chapter are to increase engagement in positive

activities, examine the relationship between behavior and mood, and
savor the positive moments. Clients are instructed in the importance
of doing positive activities, how to increase the frequency of positive
activities, and how to experience positive emotions more intensely in
those activities. To achieve this goal, clients begin by reviewing a list
of positive activities and mastery activities. They then create their own
positive activity list. They conduct mood recording to identify which
activities generate more positive emotions in their everyday lives. Then,
clients schedule positive activities, followed by a Savoring the Moment
exercise that aims to enhance the memory of the most rewarding aspect
of the activity.

Module 2: Treatment Skill Sets: Attending to the Positive

■ Duration: Three sessions

■ Corresponding therapist guide chapter: 6
■ Corresponding client workbook chapter: 6

The key concepts in this chapter are to increase one’s ability to notice
positive aspects of situations, to anticipate positive outcomes, and to
take responsibility for one’s own contribution to positive outcomes.
These are achieved by a set of thinking skills, including Finding the
Silver Linings, Taking Ownership, and Imagining the Positive. In Finding
the Silver Linings, clients are asked to identify and appreciate positive
aspects in everyday situations, no matter how negative they may seem.
Taking Ownership skills are aimed at shifting the client’s attention to-
ward their own positive contribution to a positive event in their lives.

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28

Imagining the Positive involves repeatedly imagining positive outcomes

in an upcoming event.

Module 2: Treatment Skill Sets: Building Positivity

■ Duration: Four sessions

■ Corresponding therapist guide chapter: 7
■ Corresponding client workbook chapter: 7

This chapter involves a set of experiential skills designed to cultivate

and savor positive experiences. Through daily practices of mental giving
(Loving-​Kindness), physical acts of giving (Generosity), Gratitude, and
wishing well (Appreciative Joy), clients are given the opportunity to culti-
vate positive emotions toward themselves and others. They allow clients
to shift their focus away from negative emotions such as self-​hatred,
anger, shame, or disappointment toward positive emotions such as em-
pathy, self-​acceptance, and satisfaction.

Module 3: Treatment Gains and Relapse Prevention

■ Duration: One session

■ Corresponding therapist guide chapter: 8
■ Corresponding client workbook chapter: 8

The final module reviews progress, establishes a practice plan, and

provides guidance on ways of dealing with challenging times and
barriers in the future, in order to maintain gains and minimize relapse.

Treatment Schedule

Figure 3.1 provides an overview of the recommended treatment schedule

and structure. As discussed later in this chapter (see p. 32), as the therapist,
you may wish to change the order and duration of sessions depending on
the client’s reward sensitivity deficits and resources (e.g., time).

28
29

Figure 3.1
Recommended treatment schedule.
29
30

Treatment Basics and Exercise Forms

PAT is administered face to face in an individual format. Like most other

evidence-​based psychotherapies, clients can meet with their therapists
weekly for 50 to 60 minutes. The recommended standard therapy du-
ration is 15 weeks, and program modifications can be considered (see
“Program Adaptations” later in this chapter). The order, layout, and
structure follow cognitive–​behavioral treatments, including those in the
Treatments That WorkTM series.

Exercise Forms

We designed exercises to be used daily throughout the program that are

easy for therapists to explain and for clients to use. Each exercise is first
completed in session with the therapist before the client uses it for home
practice. Make sure that your clients are provided with enough copies
of the exercise forms for their daily practices at home. Your clients and
you may photocopy all exercises from the client workbook or down-
load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT).

Encourage your clients to review the exercise instructions before starting

an exercise at home to ensure that they practice each skill as intended.
The assignments require clients to rate their mood before and after
each activity or practice, using a 0-​to-​10-​point scale, where 0 stands for
“lowest mood” while 10 stands for “highest mood”. Those ratings are a
fundamental part of mood improvement tracking. They allow therapists
to determine whether an activity works or not. If an activity or event
does not result in improvements in mood, modifications may need to be
made (see the “Troubleshooting” suggestions for each skill). The mood
ratings also provide valuable feedback, encouragement, and a sense of
accomplishment to the clients, who by the very nature of anhedonia
struggle to notice or feel positive emotions.

Exercises should be completed as instructed. Importantly, you can

model writing responses on the exercise forms to increase the chances
of client compliance. Clients sometimes complete forms retrospectively,
after having done the exercises. Yet, retrospective recollection of their

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31

exercises and mood will likely be affected by negative biases in attention

and memory, characteristic of anxiety and depression. Furthermore,
retrospective recollection means that information about in-​ the-​
mo-
ment mood changes will get lost. Lastly, the act of writing has multiple
benefits in and of itself, including “slowing the mind.” Individuals with
anxiety or depression often report that their “minds are racing” or that
they are easily “distractible.” Writing can focus attention and in turn fa-
cilitate encoding and memory consolidation about positive, rewarding
experiences that would otherwise be dismissed.

Homework

As for any evidence-​based intervention, regular homework practice is

essential. Skills within each section are intended to be practiced daily
(typically one exercise per day) for the recommended time (e.g., one
week) that we provide. Practice is encouraged no matter how simple or
easy the skills seem to the client. Repeated practice builds mastery and
is necessary to transform the skills into habits.

Of course, if clients already have mastered specific skills, consider the

program modifications outlined later in the chapter. Likewise, if more
time is needed, extend the amount of time to practice with exercises
before moving on to the next chapter. Lastly, remember that the skills
training from one section of a skill set (e.g., Actions Toward Feeling
Better) should be carried over into the next skill set (i.e., Attending to
the Positive), if clinically indicated.

Some skills will be best practiced regularly at the beginning or end of each
day (e.g., Finding the Silver Linings, Imagining the Positive, Gratitude,
Loving-​Kindness, Appreciative Joy). In contrast, others will be best prac-
ticed when scheduled during the day (e.g., Practicing Positive Activities,
Taking Ownership, Generosity). Remind clients to avoid pushing their
practices to the end of the day, when low drive and motivation may be-
come stronger impediments.

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Assessment and Monitoring

Mental health professionals may wish to screen clients for the presence
of emotional disorders using the Anxiety Disorders Interview Schedule
for DSM-​5 (Brown & Barlow, 2021), which was designed for this pur-
pose. The semi-​structured diagnostic clinical interview focuses on DSM-​
5 diagnoses of anxiety disorders and their accompanying mood states,
somatoform disorders, and substance and alcohol use. For a fuller diag-
nostic picture, including a more in-​depth evaluation of the various mood
disorders and psychoses, you may consider using the SCID-​5 (First et al.,
2016). The information derived from these interviews allows you to de-
termine differential diagnoses and to gather a clear understanding of the
level of severity of each diagnosis. A medical evaluation may be appro-
priate to rule out medical conditions that may account for or exacerbate
anhedonia.

A number of standardized self-​report inventories can be very useful for

case formulation and treatment planning, as well as evaluating thera-
peutic change. For direct measures of affect, the Positive and Negative
Affect Schedule (PANAS; Watson et al., 1988) provides state and trait
measures of mood state, again with strong psychometric properties. For
assessment of symptoms of depression and anxiety, we often use the
Depression, Anxiety and Stress Scale (DASS; Lovibond & Lovibond,
1995). This scale has excellent psychometric properties. We strongly rec-
ommend that you have clients complete both scales at the beginning of
each treatment session to assess ongoing progress and determine treat-
ment success (see ­chapter 8 in this guide).

For anhedonic symptoms in particular, the Temporal Experience of

Pleasure Scale (Gard et al., 2006) (anticipatory and consummatory
subscales) provides psychometrically valid measures of reward respon-
siveness. Similarly, the Snaith-​Hamilton Pleasure Scale (Snaith et al.,
1995) measures hedonic capacity with good psychometric characteristics.
The Dimensional Anhedonia Rating Scale (Rizvi et al., 2015) measures
aspects of interest, motivation, and effort related to reward responsive-
ness, again with good psychometric properties.

Therapists may also find it valuable to examine functional impairment

and quality of life. A number of reliable and validated measures exist,

32
3

including the Work and Social Adjustment Scale (Mundt et al., 2002),
which is perhaps most widely used in clinical settings.

Program Adaptations

Although PAT was tested and studied in the format described earlier
in the chapter (i.e., 15 individual, weekly sessions) adaptations can
be made. For example, now with improvements in technology, PAT
can be offered virtually over telehealth platforms. This may allow for
greater access.

Frequency

If schedules of the client and therapist permit twice-​a-​week appointments,

then treatment can be offered twice a week for an eight-​week duration.
Therapists might opt for this schedule if their client is of higher risk or if
time is limited. For higher-​functioning clients with limited availability
for weekly sessions, offering sessions every two to three weeks may still
be beneficial for the client, if they practice their skills regularly between
sessions.

Duration

Treatment duration can be tailored to the client’s needs. It can be ab-

breviated or extended. For example, clients may need fewer sessions de-
voted to the skills covered in c­ hapter 5 (Actions Toward Feeling Better)
if they are already effectively engaging in positive activities. Conversely,
you can spend an additional session on certain skills that seem to re-
quire more practice. However, we generally aim to complete the pro-
gram within 15 sessions.

33
34

Tailoring Treatment

In addition to tailoring treatment based on client severity (e.g., greater

severity might require more frequent sessions or spending more time on
certain skills), treatment can be tailored to client-​specific reward system
deficits. If a client demonstrates strengths in one area of the reward system
but limitations in another, then you can adapt the therapy to spend more
time on the skills that target the limitations. Recall that we focus on
three main components of the reward system: anticipation and moti-
vation for reward (wanting), attainment or savoring of reward (liking),
and learning of reward. If a client demonstrates deficits in anticipation
of reward, more time can be spent on Designing Positive Activities and on
Imagining the Positive. If clients struggle with learning of reward, it may
be beneficial to focus on Taking Ownership, Gratitude, and Generosity
earlier in treatment. For clients who struggle with attainment of reward,
then Practicing Positive Activities, Savoring the Moment, Loving-​Kindness,
and Appreciative Joy should be more strategically targeted.

We provide a list of questions in the client workbook to identify where

clients have the most deficits or difficulties with respect to aspects of re-
ward processes (anticipation and motivation, attainment, and learning).
These questions can be found in Exercise 2.1: Treatment Fit Assessment,
which is in the client workbook and also in the appendix at the end of
this therapist guide.

Group Versus Individual Format

The treatment can be adapted from individual to group format, and in

fact we have conducted PAT in group formats. Ideally groups would be
about eight to 12 members. For group formats, therapists can follow the
same recommended schedule as treatment offered in an individual format.

Involving Family Members and Friends

The extent of family and friend involvement should depend on client

preference and context. Have a thorough discussion with your clients
around how they wish to include loved ones and issues that may arise,

34
35

which could become barriers to implementing the treatment. It is im-

portant to stress that even with family involvement, the client remains
the client. Also, a Release of Information or Authorization to Disclose
will be required in many circumstances.

At minimum, we recommend that clients share their involvement in

therapy with supportive loved ones. We acknowledge that in certain
unhealthy relationships, disclosure of treatment engagement may not
be safe or prudent. Having loved ones be supportive increases the likeli-
hood of client engagement and may even improve treatment outcomes.
Ideally, the client will share the skills they are learning with loved ones
after each session.

Client Commitment

Like all other evidence-​based treatments, client engagement is essential.

Clients need to be actively engaged in session when learning, practicing,
and reviewing skills, as well as at home when completing homework.
Although skills need not be practiced daily, daily practice will improve
treatment outcome. Recommendations for frequency of practice are
provided with each skill and associated exercises. Standard motivational
enhancement techniques (e.g., reviewing treatment goals, assessing and
troubleshooting barriers, reviewing consequences, and reinforcing par-
ticipation) can facilitate engagement. If a client demonstrates insuffi-
cient engagement (e.g., minimal homework completion) for multiple
weeks, we recommend that you put the treatment on hold until the
client is able to commit to the treatment.

35
36
37

CHAPTER 4 Psychoeducation

(Corresponds to c­ hapter 4 of client workbook)

Materials Needed 37
Goals 38
Summary of Information in Chapter 4 of the Client
Workbook 38
Key Concepts 39
What Is the Mood Cycle? 39
Downward and Upward Spirals 43
Labeling Emotions 44
Homework 45
Case Vignettes 46
Troubleshooting 50
Note to Therapist About Monitoring Daily Activity and
Mood 50

Materials Needed

■ Whiteboard or a piece of paper to draw out the mood cycle

■ Exercise 4.1: A Mood Cycle You Noticed (all exercises are included
in the client workbook and also included in the appendix at the end
of this therapist guide)
■ Exercise 4.2: Positive Emotions Dial
38

Goals

■ Introduce the mood cycle and have the client record one of their
own mood cycles using Exercise 4.1.
■ Explain upward and downward cycles.
■ Introduce Exercise 4.2: Positive Emotions Dial and the importance
of labeling emotions.
■ Help clients identify additional positive emotions to include on the
exercise form.
■ Assign homework of recording a mood cycle and identifying positive
emotions.

Summary of Information in Chapter 4 of the Client Workbook

■ The mood cycle explains what leads to emotions and what emotions
lead to.
■ How we think (thoughts), what we do (behavior), and how our body
feels (physical sensations) can directly change how we feel (emotions/​
mood). Our emotions or mood can change how we think, what we
do, and how our body feels. Further, thoughts, behaviors, and phys-
ical sensations all affect each other.
■ Together, thoughts, behaviors, and physical sensations form the
mood/​emotion cycle.
■ There are positive and negative mood cycles, and there are down-
ward and upward spirals.
■ Upward spirals, like downward spirals, are self-​perpetuating mood
cycles.
■ The goal of this treatment is to help clients step into upward
spirals.
■ There is an array of positive emotions beyond happiness.
■ Labeling the full array of positive emotions increases attention to
and experiences of positivity.
■ The goal of this treatment is to enhance the diversity, frequency, and
intensity of positive emotions.

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39

Key Concepts

The key concepts of this chapter are the introduction of the mood cycle,
upward spirals, labeling emotions, and the variety of positive emotions
one can experience. Content can be covered in one session. Clients will
learn what mood cycles are and how to identify them, as well as how to
label their positive emotions throughout the week. Goals for the client are:

■ Define a mood cycle

■ Identify a positive or negative mood cycle from their week
■ Define what an upward spiral is and how it relates to the skills they
will learn in this treatment
■ Expand client vocabulary of positive emotions
■ Label positive emotions in the coming week

What Is the Mood Cycle?

The mood cycle describes the relationship between mood/​emotion,

thoughts, behaviors, and physical sensations (Figure 4.1). Each of these
constructs influences each other, with thoughts, behaviors, and phys-
ical sensations being conceptualized as three parts of mood/​emotion.
Thoughts affect emotions; physical sensations affect emotions; behaviors
affect emotions; and these relationships are bidirectional. Note too that
thoughts, behaviors, and physical sensations—​the triad of emotions—​
also affect each other, forming a cycle with relationships in all directions.

Mood cycles can be positive or negative. Positive mood cycles are cycles
with positive mood/​emotions at the center, whereas negative mood
cycles are those with negative emotions at the center. Most people come
to therapy in the hope of changing their mood or physical symptoms.
The mood cycle demonstrates that we can indirectly change how we
feel by working with our thoughts and behaviors. This is the cognitive–​
behavioral approach that the Positive Affect Treatment (PAT) uses. In
this treatment, clients learn thinking skills and behavioral skills to in-
directly change how they feel. In order for the client to understand key
concepts in this treatment, reviewing the mood cycle is essential. Often
clients struggle to differentiate between these internal experiences,
confusing a thought with an emotion or an emotion with a physical

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Figure 4.1
The mood cycle.

symptom. Further, many clients are not aware of the relationship be-
tween these constructs. Therefore, review the model with exemplars of
how emotions will shift depending on appraisals of a given situation.
Common examples are a friend passes us by without saying hello or a
sound wakes us up in the middle of the night. The former situation is
used in the client workbook.

When walking through an example, writing down the client’s answers

on a whiteboard or piece of paper (similar to what is drawn in the work-
book on pages 32–35) can help the client better visualize the connection
between emotions/​mood, thoughts, physical symptoms, and behaviors.

Below is an example of how you might introduce the mood cycle. Note
that T and C represent “Therapist” and “Client” in the following example.

T: I’d like to start us off today with an exercise. Let’s take the hypo-
thetical situation that a friend passes you by without saying “hello.’”
What might be some thoughts running through your head?
C: My friend didn’t see me. Or, my friend is angry at me because of
something I did.
T: Okay, great. Let’s go with the thought that your friend is angry at you
for something you did wrong. If you believe that you friend is angry
at you for what you did wrong, what would you feel?

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C: I would feel bad.

T: For sure. Maybe you would feel some guilt?
C: Yes.
T: Okay, so let’s draw an arrow from the thought “My friend is angry at
me for something I did” to the emotion of guilt. [See Figure 4.2.]

Figure 4.2
An example of a negative thought leading to a negative emotion.

T: Now, if you felt guilt, what do you think you would feel in your body?
Tension anywhere?
C: Yes, probably a heaviness and difficulty making eye contact. [See
Figure 4.3.]

Figure 4.3
An example of a negative thought and negative emotion leading to physical symptoms.

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T: Let’s add that. And what would you do if you felt guilt or thought you
did something wrong?
C: I would call my friend and apologize.
T: Okay, let’s write that down. What are you noticing here? [See
Figure 4.4.]

Figure 4.4
An example of the full mood cycle.

C: They are all connected, like a circle.

T: Absolutely! They form a cycle. We call this the mood cycle, with mood
or emotions in the center. We like to think of mood as having three
parts—​thoughts, behaviors, and physical sensations—​which not only
influence mood but also influence each other.
C: This makes a lot of sense.
T: Let’s go over another example, but this time, you think, “That Bryan.
He always has his head in the clouds, probably thinking about the
next song he’s going to write.” What emotions and physical symptoms
do you think you would feel then?
C: I would probably chuckle a little and smile. I am not sure what emo-
tion though.
T: Would you possibly feel amusement?
C: That sounds about right.
T: What would you do?
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C: I would probably call him and make a little fun of him for being so
oblivious he didn’t even say hi.
T: Absolutely. Notice how the mood cycle fits even for positive emotions.

After introducing the mood cycle, have clients complete their own ver-
sion, preferably one they noticed during the past week. It can be positive
or negative, or they can complete a mood cycle for each. Given anhe-
donia, clients will struggle most with generating a positive mood cycle.
They can record these mood cycles on Exercise 4.1: A Mood Cycle You
Noticed, which appears in the client workbook and also in the appendix
at the end of this therapist guide.

In sum, the following concepts should be covered with the client:

■ Thoughts → emotions: How we interpret or think about a situation

directly affects how we feel.
■ Behaviors → emotions: What we do has a direct effect on how we feel.
One way to highlight this concept is to ask the client what emotions
they feel when doing their least-​liked activity versus their favorite
activity.
■ Physical sensations → emotions: Physical sensations or symptoms also
influence our emotions. Provide clients with examples of how they
feel with physical pain versus no pain.
■ Mood/​emotions: Things that we think, do, and feel physically affect
our mood and can be thought of as parts of mood.
■ Thoughts, behaviors, and physical sensations all have an effect on
our emotions. The reverse is also true: Our mood and emotions af-
fect what we think, do, and feel in our body.
■ Finally, each part of the mood triad affects other parts of mood—​
they are interconnected.
■ In this treatment, we are having clients learn thinking skills and
behavioral skills to indirectly change how they feel.

Downward and Upward Spirals

Downward spirals are self-​ perpetuating cycles of negative emotion,

which are maintained by negative thoughts and behaviors (Garland
et al., 2010). For example, a negative thought leads to another negative
thought, which leads to a negative emotion, which leads to more negative

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thoughts. These negative thoughts lead to problematic behaviors, which

maintain the negative emotion and fuel the negative thoughts. Notice
how these spirals are an extension of the mood cycle we just described.

Most therapists have countless examples of downward spirals that

their clients present with. However, less recognized are upward spirals.
Upward spirals follow the same pattern as downward spirals, but in-
stead of maintaining negative emotion, they maintain positive emotions
(Garland et al., 2010). Upward spirals were first identified following
research that demonstrated an association between current and future
positive experiences (Fredrickson & Joiner, 2002). Other research since
then has demonstrated that experiencing positive emotions facilitates
cognitive reappraisal (Tugade & Fredrickson, 2004). It dampens atten-
tional biases toward the negative (Smith et al., 2006), and broadens
attention and builds resources (Fredrickson, 2001).

A primary goal of PAT is to help clients step into upward spirals by

practicing skills that have been proven to predict positive emotions.

In sum, the following should be covered with clients:

■ Upward and downward spirals as self-​maintaining systems

■ Effect of upward spirals on positive emotions, appraisals, attention,
and resources
■ Client’s experience of upward or downward spirals in the last week
■ How upward and downward spirals are an extension of the
mood cycle
■ How these spirals relate to skills in this treatment (i.e., the intention
of skills is to help clients step into upward spirals)

Labeling Emotions

Individuals who are depressed can have difficulty labeling emotions

(alexithymia) (Honkalampi et al., 2001). Since people with anhedonia
experience fewer positive emotional states overall, their repertoire for
describing positive emotions is typically limited. Building repertoire
requires discriminating among different strengths and types of posi-
tive emotions (e.g., joy, thrill, contentment), and such discrimination
facilitates attention to and encoding of internal states (e.g., physical
sensations, thoughts) associated with each positive emotion. Training

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to attend to internal states associated with hedonic feelings offsets the

deficits in sustained attention to positive stimuli that characterizes
depression and anhedonia (Shane & Peterson, 2007), with a preference
to attend to negative stimuli (Koster et al., 2005). Hence, the process
of labeling positive emotions is likely to enhance attention to positive
experiences that will increase the attainment of reward.

For these reasons, labeling positive emotions is introduced as a skill.

Clients typically have a more varied vocabulary for negative emotions
than positive emotions. Indeed, clients often struggle to identify any
positive emotions beyond love or happiness. Part of this section is to ex-
pand the positive emotion vocabulary of clients, who will then use these
feeling words to label their emotional experience throughout treatment.
Another purpose of this skill is to help clients more accurately label their
emotions to increase the salience of their emotions.

To introduce the exercise, we use Exercise 4.2: Positive Emotions Dial,

which can be found in the client workbook and also in the appendix at
the end of this therapist guide. The dial is designed so that clients can see
that there is not only a variety of positive emotions, but that they vary in
intensity too. For example, satisfaction is a lower level of intensity than
happiness, which in turn is lower in intensity than elation.

Having the client read through the various positive emotions and dis-
cuss their reactions can start a helpful dialogue around their current
experience with positive emotions. If there are some positive emotions
that clients already experience, they can annotate it on the chart. If they
notice some positive emotions missing from the chart, they can add
more. Finally, clients can star, circle, or underline any emotions that
resonate most with them.

Homework

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to:

■ Complete one full Exercise 4.1: A Mood Cycle You Noticed for an
event over the next week.
■ Practice identifying and labeling positive emotions.

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■ Add additional positive emotions they might notice missing from

Exercise 4.2: Positive Emotions Dial.

Case Vignettes

Note that T and C represent “Therapist” and “Client” in the following

case vignettes.

Case Vignette #1

In the following vignette, the therapist has introduced the mood cycle
and downward and upward spirals. The client is now asking follow-​up
questions for clarification.

C: Okay, so I definitely understand what negative mood cycles are. I have

them all the time. I even see how they relate to downward spirals. For
example, just yesterday, I had the thought, “My boss is going to fire
me.” This led me to feel incredibly anxious, which made me really
nauseous. So I decided to take the day off. But all I did then was lie
in bed watching TV all day and worrying more. And that made me
feel more anxious and sick. Now today, I have so much work to do
that I actually feel worse now than I did yesterday.
T: It seems like yesterday and today have been really rough for you. I am
sorry to hear that.
C: Yes, it hasn’t been great.
T: But it also sounds like you have a really good understanding of these
concepts and are spot on at identifying your own negative mood cycles
and downward spirals.
C: I mean, I get all that. I am just not sure I understand positive mood
cycles and upward spirals.
T: Well, then, let’s definitely talk more about them. I would like to
understand better what specifically about them is holding you up
right now. Let’s start with the positive mood cycle. Is there some-
thing specific about the positive mood cycle that you are con-
fused about?
C: No, just everything.

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T: Okay, then let’s tackle everything. Since you understand the concept
of a mood cycle more generally, especially a negative mood cycle, let’s
start with what makes a mood cycle positive versus negative.
C: Okay, I think I know this. A positive mood cycle is just one that makes
you feel good.
T: Generally, yes. A positive mood cycle includes positive emotions
or emotions that we enjoy, like love, interest, excitement, and joy,
whereas, a negative mood cycle is one that includes negative emotions
or emotions that we typically don’t like to have—​like anxiety, sadness,
and anger.
C: I guess I get all that. What I don’t get is what that looks like for me.
How can a positive emotion lead me to feel good in my body or lead
me to do an action?
T: Great questions. The best way to answer is by going over an example.
Drawing it out can really help, too, so as we go through the example,
I will be drawing it out on the whiteboard.
C: Okay. Should I also record this on my workbook exercise form?
T: That would be a great idea. Do you have an example from the past
day or week when you felt a positive emotion, like contentment, sat-
isfaction, love, excitement, curiosity, interest, amusement, or pride?
C: Well, definitely not pride. And I don’t know the last time I felt any hap-
piness. Hmm (thinking). What were those positive emotions again?
T: Interest, curiosity, amusement, excitement, love, satisfaction . . .
C: I guess I feel love. I don’t feel it strongly anymore, but I know it’s there.
T: Fantastic. And when was the last time you actually felt the emotion,
rather than just knowing it was there?
C: The last time I felt love? Hmm, well, the last time I felt it was almost
two months ago. My daughter got accepted to her dream college. She
wants to become an engineer for NASA. I felt like my heart was going
to burst, I felt so much love for her.
T: Wow, congratulations! That is such an accomplishment. It sounds like
you may have also felt some pride for your daughter.
C: Pride? No, it wasn’t me who got her into her dream college. It was all
her. She is incredible.
T: Well, if not pride, then some happiness for her?
C: I definitely felt happiness for her.
T: When she opened the email and you felt this love and happiness for
her, what did you feel physically in your body?

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C: I don’t know. Nothing, I think.

T: Well, even now as you describe your daughter opening her acceptance
email, I see some changes in your face. What are those?
C: A smile, I guess. (laughter)
T: Absolutely. What else?
C: I feel some tears too.
T: I notice that as well. Maybe they are some tears of joy or love?
C: Yea, definitely. (client sniffles)
T: Let’s add all of this to the mood cycle. Love and joy lead to smile and
tears. Can you now see how a positive emotion might lead to a change
in physical sensations?
C: Yes. So is a smile a physical sensation or a behavior?
T: Great question. When it’s automatic or involuntary, it’s considered
a physical sensation. However, if it is something that we consciously
decide to do, then it’s an action or behavior. That means that a smile
can either be a physical sensation or behavior, depending on whether
we are voluntarily doing it.
C: I see.
T: Speaking of behavior, what did you do after feeling that love and
happiness for your daughter?
C: I just gave her a big hug and whispered in her ear how much I love
her and how happy I was that she got into her dream college.
T: That sounds like it was a really loving moment.
C: It was. I felt even more love after giving her that hug, and I just felt
so connected to her.
T: Wow, so not only did your emotion lead to your behavior of a hug and
kind words, but those behaviors led to more positive emotion.
C: Definitely. And then, I couldn’t stop thinking about how my daughter
is going to do so well in life. Or at least she’s on the path for that. I felt
really good that morning.
T: Well, let’s definitely jot that down because it sounds like you just
described a positive mood cycle and an upward cycle. The positive
emotions you felt led to physical symptoms and a behavior, which led
to more positive emotion, which led to positive thoughts, which led to
a change in mood for a good portion of the day.
C: Yes, I guess that’s right. Okay, I get upward spirals and positive mood
cycles now.

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Case Vignette #2

This is a vignette where the therapist is introducing how to label emotions

to a client who has struggled with chronic depression for most of his life.

T: We are going to work on skills to increase the variety of positive

emotions you experience. In other words, to feel more than just happi-
ness—​to feel other emotions like interest, pride, gratitude, fulfillment,
and elation.
C: Heh, elation? Yeah, not going to happen.
T: Can you say more about that?
C: I just can’t remember the last time I felt anything positive, and to
think that I’m going to start feeling something like elation sounds ri-
diculous to me.
T: I hear that. Elation may not be something that we can expect right
now. The good news is that there are other positive emotions—​like
satisfaction, pleasure, curiosity, and connection—​that may be more
realistic. We will go over this more when we review the Positive
Emotions Dial in a moment. Do you think these other emotions are
more reasonable for you?
C: I guess so.
T: The other thing that I really want to stress is that this treatment was
specifically designed for someone with your symptoms and your his-
tory. It has helped many people with chronic depression start feeling
positive emotions again, even if it has been years since they last re-
member experiencing them. Does that sound more reassuring?
C: It does.
T: So to get started, let’s talk about labeling emotions. Most of us can
label a ton of negative emotions with minimal difficulty—​like anger,
frustration, annoyance, irritation, shame, and anxiety. Does that
sound familiar?
C: Yeah, totally.
T: That’s true for most people. Even though most people can think of lots
of negative emotions, they typically struggle to think of any positive
emotions other than happiness.
C: That also sounds like me.
T: To help with that, we created this figure for you to reference (show
Exercise 4.2: Positive Emotions Dial). Let’s go over this now.

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Troubleshooting

Since lack of positive emotions is inherent to anhedonia, some clients

may not have an example of a positive mood cycle. If your clients
cannot generate their own positive mood cycle, encourage them to
identify a positive mood cycle they have noticed in a family member or
friend, or even one they’ve seen on TV or in the movies. Have clients
practice identifying any positive mood cycles—​regardless of whose it
is—​before starting to build their own.

Some clients report that it has been years since they have experienced
a positive emotion, and they express incredulity at ever being able to
experience a positive emotion, let alone a variety of positive emotions.
Validate their experience and reassure them that PAT was designed spe-
cifically to help them increase the intensity, frequency, and variety of
positive emotions.

Some clients may get stuck on wanting only happiness and indicate
they are not interested in a variety of positive emotions. In this case,
emphasize that we have an array of emotions (both positive and neg-
ative) for a reason. Explain that emotions are meant to be a form of
communication with others and ourselves, and that emotions also help
us learn. For example, curiosity and playfulness are emotions that help
us gain knowledge about the world around us.

Some clients may be fearful that they will get stuck in an upward
spiral. Explain that it is not possible to get stuck in an upward
spiral, unless they have a history of clinical mania. If the client
does have such a history, it will be important to discuss possible
triggers of manic episodes and avoid those throughout the course of
treatment. Note that none of the PAT strategies can alone trigger a
manic episode.

Note to Therapist About Monitoring Daily Activity and Mood

Typically, the “Actions Toward Feeling Better” skill set will be

administered following the “Psychoeducation” module. If you
follow this recommended order of skills, then we suggest that you

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introduce and assign homework from c­ hapter 5’s “Monitoring Daily

Activity and Mood” section in the same session that you review the
“Psychoeducation” module. The homework assignment for that section
of ­chapter 5 is best completed before introducing the skill of Designing
Positive Activities.

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MODULE 2

Treatment
Skill Sets
54
5

CHAPTER 5
Actions Toward
Feeling Better

(Corresponds to c­ hapter 5 of client workbook)

Materials Needed 56
Goals 56
Summary of Information in Chapter 5 of Client Workbook 56
Key Concepts 57
The Importance of Positive Activities 57
Structure of “Actions Toward Feeling Better” 58
Monitoring Daily Activity and Mood 59
Homework for Monitoring Daily Activity and Mood 60
Case Vignettes for Monitoring Daily Activity and Mood 61
Troubleshooting for Monitoring Daily Activity and Mood 63
Designing Positive Activities 64
Case Vignettes for Designing Positive Activities 65
Troubleshooting for Designing Positive Activities 67
Practicing Positive Activities 69
Homework for Practicing Positive Activities 71
Case Vignettes for Practicing Positive Activities 71
Troubleshooting for Practicing Positive Activities 74
Savoring the Moment 76
Case Vignettes for Savoring the Moment 78
Troubleshooting for Savoring the Moment 80
56

Materials Needed

■ Exercise 5.1: Daily Activity and Mood Record (all exercises are in-
cluded in the client workbook and also included in the appendix at
the end of this therapist guide)
■ Exercise 5.2: Positive Activity List
■ Exercise 5.3: Positive Activity List Through Mastery
■ Exercise 5.4: My Positive Activity List
■ Exercise 5.5: Positive Activity Scheduling
■ Exercise 5.6: Savoring the Moment

Goals

■ Review content from last session and answer any questions.

■ Discuss purpose of monitoring daily activities and mood and assign
for homework.
■ Educate client about the importance of positive activities.
■ Review list of positive activity examples and assist client in creating
own list.
■ Introduce positive activity exercise, complete in session, and assign
3-​5 positive activities for homework for the upcoming week.
■ Introduce Savoring the Moment exercise, complete in session using
events from the prior week, and encourage self-​guided savoring prac-
tice between sessions.

Summary of Information in Chapter 5 of Client Workbook

■ Change in behavior directly influences how we feel and think.

■ Low positive mood is often a result of insufficient pleasing or re-
warding activities. Engaging in positive activities is a way to step into
the upward positive mood cycle.
■ The practice of planning and practicing positive activities, and then
savoring the moments during those activities, will increase capacity
to be interested in and motivated to do more positive activities, to

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appreciate them in the moment, and to feel the positive effects.

Noticing the positive effects on mood state will help clients learn
that their efforts lead to rewarding outcomes.

Key Concepts

In this chapter, the concept of positive activities is introduced. Clients

will learn to appreciate the direct link between behaviors and thoughts
and feelings. They will learn how engaging in positive activities leads to
a positive mood cycle and the upward spiral of their emotions. Clients
plan their positive activities with you and then practice the skills be-
tween sessions. Use subsequent sessions to review the skills and deepen
the intensity of rewarding emotions by savoring the moments through
memory specificity training.

Goals for the client are to:

■ Learn to identify positive activities.

■ Learn about positive activity scheduling and its impact on positive
emotions (the skills of Designing Positive Activities and Practicing
Positive Activities).
■ Learn to deepen the impact of positive activities through Savoring
the Moment.

The Importance of Positive Activities

The goal of this chapter is to augment positive mood through repeated

engagement with positive activities and Savoring the Moment exercises.
The behavioral component of the mood cycle is purposefully introduced
early in treatment. It is the focus of the first half of treatment, and should
be continued during the second half of treatment, where new skills of
thinking positively and building positivity are added. Research suggests
that early behavioral change is associated with early-​in-​treatment thera-
peutic gains. Those gains are essential to maintain motivation and drive,
particularly in individuals whose core deficit is often a lack of motiva-
tion and drive.

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Positive activity scheduling is rooted in Lewinsohn’s conceptualization

of etiology and maintenance of depression (Lewinsohn, 1974). The
core idea is that lack of positive reinforcement causes or is associated
with depressive states. That is, individuals with depression engage in
fewer positive activities, and if they do engage, they do not experience
these activities as rewarding. Reactivation of positive behaviors has been
shown to be effective in treating depression (Dimidjian et al., 2006;
Dobson et al., 2008). Consistent with Lewinsohn’s original model of
behavioral activation, the focus in Positive Affect Treatment (PAT) is on
activities with a high probability of generating positive emotions. These
are activities that are inherently pleasant or rewarding, that provide a
sense of accomplishment and/​or mastery, or are consistent with valued
actions. PAT adds another component of Savoring the Moment through
memory specificity training to enhance hedonic impact (initial response
to reward). This is essential to prevent dismissal of the positive activities
as being irrelevant or unimportant. Instead, clients are trained to value
the most positive elements through in-​depth focusing of attention on
the situational and sensory details.

By Designing Positive Activities, the skills taught in this chapter target

deficits in anticipation of reward, or wanting. By Practicing Positive
Activities and the savoring of the most positive moments of those activ-
ities through Savoring the Moment, the skills in this chapter also target
the attainment and appreciation of reward, or liking. By emphasizing
how positive activities change mood state, the skills also target learning
of reward (i.e., what actions lead to positive outcomes).

Structure of “Actions Toward Feeling Better”

The first session of the “Actions Toward Feeling Better” chapter includes
(1) rationale for positive activities and (2) guidance on daily activity and
mood monitoring. After a week of daily activity and mood monitoring,
the next session involves (1) reviewing the daily activity and mood
monitoring, (2) developing a positive activity list, and (3) planning for
positive activities. After a week of engaging in positive activities, each ses-
sion thereafter involves (1) review of positive activities and (2) savoring
of the most positive moments of the positive activities completed in the

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prior week. Clients are also encouraged to practice savoring of positive

activities on their own between sessions.

While “Actions Toward Feeling Better” is the focus of the first half
of PAT, encourage clients to continue engaging in positive activities
and Savoring the Moment exercises throughout the entire treatment.
Reinforce clients’ continued engagement in positive activities as new
skills are introduced in the second half of treatment.

Monitoring Daily Activity and Mood

The monitoring of activities prepares clients to identify which activi-

ties in their lives already improve their mood, and which ones do not.
Instruct clients how to keep track of their activities and mood using
Exercise 5.1: The Daily Activity and Mood Record, which can be found
in the client workbook and also in the appendix at the end of this ther-
apist guide. The mood rating used here is the same as the mood rating
used throughout treatment. Mood monitoring is an important compo-
nent of cognitive–​behavioral therapy and PAT for several reasons. First,
as described previously, clients with anhedonia report several deficits in
reward responsivity, including deficits in noticing the hedonic impact
of pleasant events, savoring reward, and Pavlovian and instrumental re-
ward learning. Given that many positive activities are unlikely to re-
sult in significant shifts in positive mood for clients with anhedonia at
the beginning of treatment, noticing even small changes in mood is an
important component of learning to deepen the experience of reward.
Second, tracking changes in mood across activities improves reward
learning as clients develop awareness between engagement in specific
activities and changes in mood. Therefore, before and after several activ-
ities in PAT, we ask clients to rate their mood on a scale from 0 (lowest
mood) to 10 (highest mood).

After explaining the mood rating, explain the four benefits of using the
Daily Activity and Mood Record:

1. It informs both therapist and client where their start point is, which
is important for monitoring progress.

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2. It creates a clear objective and accurate description of the client’s

daily activities.
3. It illustrates where the client has time for more positive activities.
4. It elucidates the relationship between activity and mood.

Ask clients to monitor all of their activities over the course of a week.
Those activities include the number of hours the client sleeps, exercises,
works, eats, plays, and engages in free time. Explain that daily monitoring
is a better way of gauging the relationship between activities and mood
state than is retrospective estimation.

Furthermore, monitoring allows evaluation of the linkage between be-

havioral activities and positive mood state. The recognition that certain
activities enhance positive mood more than others provides motivation
to repeat those activities and engage in other activities that are expected
to lift mood. Explain to clients that they are unlikely to feel motivated to
engage in specific activities (e.g., brushing teeth) if there were no direct
benefit; explain that the same principle applies when targeting positive
activities.

Review the Daily Activity and Mood Record at the subsequent session.

Homework for Monitoring Daily Activity and Mood

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to
complete an Exercise 5.1: Daily Activity and Mood Record every day
for a week as accurately and thoroughly as possible. Remind clients to
monitor their mood before and after each of their activities on a scale
of 0 for “lowest” to 10 for “highest” mood.

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Case Vignettes for Monitoring Daily Activity and Mood

Case Vignette #1

This vignette demonstrates how to explain the purpose of activity and

mood monitoring.

C: Okay, I understand what I am supposed to do over the next week,

but I just don’t see how this will help me improve my mood. If at all,
it probably will make me feel worse to see how little I am doing and
how bad it makes me feel.
T: I hear your concern. I can assure you that it is a common one. Why
would you want to be reminded of the things that make you feel
bad? But there is a reason for what I am asking, and that is to get a
baseline.
C: A baseline?
T: Let’s go over an example to demonstrate what I mean. You have a
daughter in high school, is that right?
C: Yes.
T: Okay, if she was getting low scores on her tests, what would be one of
the first steps you would take?
C: I would definitely check in with her to see how she is doing.
T: Absolutely. You’d do some assessment. What else would you assess?
C: Maybe how much she is studying and how she is studying?
T: Absolutely! We need to know her baseline—​ what are her study
habits—​in order to figure out if changes need to be made.
C: Oh, I get it. Monitoring my daily activities will tell us if we need to
change my activities to different activities.
T: Yes, and also tell us if we need to schedule more activities.
C: Okay, I get it. Why do I have to record it every day though? I can just
tell you right now what my days are like.
T: There are several good reasons why it is helpful to gather this informa-
tion in real time as supposed to retrospectively. Can you think of one?
C: Hmm . . . I am not sure.
T: One reason is that if you are not doing things in real time, you have
to rely on memory. How accurate do you think memory is if you wait
until the end of the week to remember what you did at the beginning
of the week?
C: Horrible. I can’t even remember what I did yesterday!

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T: Absolutely. Our memories are not great. And, our memories tend to
be less accurate when we are stressed, depressed, or anxious.
C: Well, that’s me.
T: Yes, so the daily monitoring helps to keep things more accurate.

Case Vignette #2

This vignette addresses situations when clients do not complete their

monitoring record.

C: I am sorry I did not complete the record sheet.

T: Well, let’s talk more about that. Would you mind sharing the reasons
why you did not?
C: I just did not feel motivated.
T: Okay, I can understand that. In fact, that’s the issue we are targeting
with this treatment.
C: And honestly, I felt a bit embarrassed because I don’t really do any-
thing worth sharing.
T: I totally hear that. It is very hard to share with someone, including
your therapist, something that you feel embarrassed about. What are
you concerned might happen if you share with me?
C: That you will judge me for having so few activities on my record sheet.
T: Ah, I see. Well, I can assure you that nothing you write down will
lead me to think anything different of you. In fact, I am expecting
there to be very few positive activities, because it is part of the reason
you are here.
C: Really?
T: In many ways, it even helps to have a monitoring record with only
a few positive activities. That means that there is a lot of room for
change!
C: (smiles and laughs a little) I guess I can see that. But isn’t part of the
reason I am recording my activities to see what makes me feel good?
T: Yes, and if there aren’t any of those activities, then we will add them.
C: So other people also feel they don’t do anything?
T: Yes, but once they monitor their activities for a whole week, they are
often surprised that they actually do much more than they thought
they would. And some of those activities do improve their mood, even

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when it is just a little bit. Why don’t we fill out the form together and
see what activities you remember doing yesterday and today and how
they made you feel?

Troubleshooting for Monitoring Daily Activity and Mood

When reviewing the week of Daily Activity and Mood Record sheets,
the goal is to reinforce how many positive activities the client completed
and how many of those activities were enjoyable, emphasizing that mood
increases as a function of the number of positive activities completed.
The objective indicator is the increase in the mood rating. You may no-
tice that some clients’ mood is quite good already (e.g., 5 or 6 out of
10) and increases nicely (e.g., increase to 8 out of 10) after the activity.
However, some clients may have a very low mood throughout most of
the day(s) (e.g., 1 or 2 out of 10) and record little or no changes in mood
state after the activity (e.g., increase to 3 out of 10). And in some clients,
mood state may even worsen after an activity. Some clients may become
self-​critical because their mood ratings are low, and get stuck in the be-
lief that an activity should be rewarding now because it was rewarding in
the past. Or just because their family or friends find it rewarding, they
should find it rewarding too.

Be aware of negative mood cycles and downward spirals here. In this

critical, initial phase of the treatment, clients may give up because they
see their lack of activities and/​or enjoyment as evidence that nothing
will help and nothing will change. They may even think that they are
responsible for their mood state being so low or unresponsive to activi-
ties, or see it as a sign of failure. Remind your clients that the purpose of
completing the Daily Activity and Mood Record is to determine a baseline
or starting point. The goal of the treatment is to increase how much of
their time is spent on pleasurable activities. In turn, this will improve
their positive mood and decrease their negative mood.

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Designing Positive Activities

The first step is to provide a therapeutic rationale for positive activities.

Teach clients about how avoiding situations that have the potential to
be rewarding leads to feelings of isolation and thoughts of failing. Ask
clients whether they have examples of such negative cycles. You then
explain how behavioral changes can change thoughts and feelings. Also
explain how research has shown that clients with depression tend to
withdraw from activities they previously found rewarding and how this
can worsen their symptoms. Explain that reluctance to engage in poten-
tially rewarding activities is the natural outcome from a lack of drive,
motivation, or the inability to anticipate that an event will be positive,
as well as the inability to derive enjoyment from the activity. The com-
bination fuels the downward spiral. To replace this downward negative
cycle with an upward positive cycle, clients will schedule 3-​5 positive
activities each week, and they will savor the experiences. “Feel better”
behaviors or pleasurable activities promote physical and mental health
and positive thoughts and feelings.

The next step is to identify activities that the client currently enjoys or
has enjoyed in the past; these may also be new activities. Most impor-
tantly, the activity needs to have a high probability of increasing mood
either instantaneously or soon after completion.

Present the client with examples of positive activities shown in

Exercises 5.2 and 5.3; these can be found in the client workbook and
also in the appendix at the end of this therapist guide. Exercise 5.2
includes examples of hedonic activities, such as taking a warm bubble
bath. Exercise 5.3 includes examples that improve mood through mas-
tery, such as meeting a deadline. Use prompting questions (e.g., “Which
of those activities do you currently enjoy?” “Which have you enjoyed in the
past?” “Are there some you have always wanted to do but have never tried?”).
Instruct clients to write a C for “currently enjoy,” P for “enjoyed in the
past,” and T for “trying out something new” next to the relevant items.

The next step is for clients to create their own positive activity list (see
Exercise 5.4: My Positive Activity List, which can be found in the
client workbook and also in the appendix at the end of this therapist
guide). Again, this list can include things clients once found enjoyable

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or activities that build a sense of mastery. A good amount of activi-

ties should involve social interactions. Research has shown that social
interactions are fundamental sources of positive affect (Snippe et al.,
2018). Social interaction combats feelings of isolation and a lost sense
of connectedness. Individuals who are depressed and withdraw from
friends and loved ones are more vulnerable to hopelessness and despair.

As clients generate their own list on the exercise sheet, remind them
to use items they endorsed in Exercise 5.2: Positive Activity List. You
should encourage clients to add examples that bring value to their lives,
such as “helping a friend” or “improving my health.” Remind clients
to include activities that bring immediate enjoyment or reward as well
as ones that eventually will produce feelings of mastery, ownership, or
contribute to valued actions (or other positive emotions) when accom-
plished. Activities should vary in the amount of time they take. Help the
client to find a good balance between easy-​to-​do, quick activities such as
“resting for 10 minutes with my eyes closed” to more complex ones such
as “cooking dinner for a friend.” All activities should be measurable.

Case Vignettes for Designing Positive Activities

Case Vignette #1

This vignette demonstrates how the therapist can handle situations

where clients struggle to identify and schedule smaller activities that can
be practiced daily.

T: What do you think are some activities you can add to your activity list?
C: Hmm, well, I can add going on vacation. I used to love doing that. . . .
I can also add celebrating holidays and birthdays with friends.
T: Okay, we can certainly add those to your activity lists. What are some
other activities that you can do daily?
C: Daily? I’ve been wanting to write a book. I can write my book
every day.
T: I am glad to see you are excited about the idea of going on vacation,
celebrating your birthday with friends, and writing a book. I would
call these “big-​ticket” events. Do you know what I mean by that?
C: They are big things to plan for, or they don’t happen often?

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T: Exactly. Most of us love the idea of taking a break or celebrating with

loved ones, and we can easily imagine that they will make us feel
good. Those occasions are special because they do not happen every
day. They also take a good deal of planning. But because they happen
rarely and take some planning. It is important to also add activities
to your list that ensure you get a frequent boost of happiness. Can you
think of any of those?
C: Hmm . . . not really. Most of the things I do I really don’t enjoy.
T: Are there things you have stopped doing because you felt you did not
have energy for them?
C: Yeah, like running.
T: Great! Let’s add that to your activity list. What about another activity
that you like but have stopped?
C: Maybe reading a book to my son?
T: That sounds like a great one! Let’s add that to the list.

Case Vignette #2

This vignette demonstrates how to help clients generate items on their

Positive Activity List that range in level of difficulty.

T: Great work coming up with 10 activities! What do you notice when

looking at the difficulty level?
C: I rated them all between a 6 and a 10.
T: Yes, exactly. They are rated on the high end.
C: Yes. Is that a problem?
T: It’s good to have a few difficult ones on your list. And you have
identified activities that have a high likelihood of generating positive
emotions, and can boost your sense of mastery or connectedness.
C: That’s what I thought.
T: But we also want to make sure you add activities to the list that are
easy, ideally with a difficulty level below 5. Can you think of some
of those?
C: Sure. Would doing yoga be a good example?
T: If it is likely to increase your positive mood, then definitely yes!
What about some other ones that don’t take up a lot of time and are
easy to do?

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C: I don’t really know. One thing I kind of stopped doing is tending to

my garden. It’s easy to do and does not take much time, but somehow
I have not felt motivated to do it.
T: That sounds like a great one to me! Let’s add that one to the list too.

Troubleshooting for Designing Positive Activities

The concept of positive activities can evoke strong hesitation. Clients

may indicate that they “just don’t feel like doing anything” or “just don’t
see the point of addressing behavior when it’s the way I feel that’s the
problem.” Such thoughts are understandable, since, by the very nature of
anhedonia, clients often lack motivation and drive. They can no longer
imagine that an activity “feels” good, especially when they have stopped
engaging in most or especially when they derive no pleasure from them.
It can also be the case that clients still enjoy activities but have trouble
initiating them because they have difficulty seeing the connection be-
tween effort and outcome. Because of these inherent challenges, be
validating and supportive, while indicating that the disbelief or hesi-
tation to engage in positive activities is the very thing this treatment is
designed to address.

You can assure your clients that their concerns are understable and
common, while re-​emphasizing that joy develops as one engages in
joyful activities. Indicate that “getting started” is often the hardest part.
Explain to clients the idea of the first law of inertia: “A body at rest will
remain at rest, and a body in motion will remain in motion unless it
is acted upon by an external force”—​or, in the context of anhedonia,
“Once you get in motion, it will be easier to stay in motion.” You can
ask clients for examples of when they thought it would be impossible to
get started on something because they felt they lacked energy, the task
felt overwhelming, or they just could not imagine that it would bring
them any positive feelings. The goal is to find examples from the past
of discovering that once clients decided to start, it was much easier to
get going. The activity may have even resulted in a greater feeling of joy,
sense of ownership, or accomplishment than they had anticipated.

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Be prepared to repeat the therapeutic rationale for behavioral change,

particularly when clients are fixated on the idea that they need to first
“fix” their negative thoughts or feelings, or negative life circumstances,
before they can take action. This idea can be intensified in clients who
feel trapped in an adverse situation, such as a problematic partnership,
a toxic work situation, or challenging living circumstances. Likewise,
clients can have physical restrictions due to medical illness or other
factors. It is important to listen empathically and address crises where
appropriate, but to return quickly to the idea that we may not have
control over many things in life but we almost always can have con-
trol over our own actions. This is a strong and hopeful message that
redirects clients away from needing to “fix what’s wrong before enjoying
the good.”

Research has shown that while cognitive–​behavioral therapy successfully

decreases negative mood, it is less successful in increasing positive mood.
Clients treated with PAT show significant improvements in both neg-
ative and positive domains. You should remind your clients of those
findings, particularly those clients who are more familiar with more tra-
ditional forms of psychosocial treatments.

For some clients, identifying current or past positive activities can be ex-
tremely difficult. Research has shown that clients who are depressed can
have difficulties remembering positive events from the past. Specifically,
depression is associated with deficits in generating vivid past (Werner-​
Seidler & Moulds, 2011) positive mental images, and devaluation of
positive memories (Speer et al., 2014). As a result, they no longer im-
agine past activities as being joyful (even when they once used to be).
Validate the client’s feelings and ensure them that their experience is not
uncommon. Encourage clients to think far back to activities from their
childhood that they found positive (foods, outdoor activities, travel,
social activities). You can also remind clients that many activities we
do during the day may not necessarily feel rewarding at the moment,
but they provide a sense of accomplishment or ownership soon after.
Furthermore, explain that every step counts, and the smallest sense of
positive emotion, even if tiny, is a step in the right direction.

It may not be difficult for some clients to list several activities, but most
or all of these activities are rated as difficult to accomplish (greater than

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7 on the scale of 0 to 10). This is not uncommon in clients who are

severely anhedonic or depressed, since any activity feels overwhelming,
even when it could be ultimately joyful and rewarding. Here again, it
is important to remind the client of the law of inertia: It is the “getting
into action” that is the hardest part. Encourage clients to break down
the activities into easier-​to-​achieve ones. For instance, instead of listing
“going on a run,” have them consider “taking a walk around the block.”
It is essential that at least some activities’ difficulty rating is below 5,
ideally between 0 and 4.

Some clients struggle to understand why the activities should be ob-

servable. Explain that choosing activities that are observable by others
or that are otherwise measurable makes it easier (and more rewarding)
to monitor positive mood change. Examples such as, “I am going to try
to feel better or think more positively” cannot be measured in objective,
observable terms. Without measurement, it is not possible to conclude
that an action was taken or to rate the mood effects of such an action.
Instead, clients are prone to dissatisfaction with thoughts like, “This is
never going to change.”

Finally, encourage your client to avoid activities that have very little
probability of being rewarding. For instance, adding “cooking dinner
for a friend” to the list can be positively reinforcing if the client likes
cooking. It will not be rewarding, however, if the client does not enjoy
cooking. The goal is not to identify situations or events that the client
avoids for reasons of fear; rather, the goal is to practice hedonic activities.

Practicing Positive Activities

Until this point, positive activities have been identified and a baseline of
activities and associated mood has been established by monitoring over
the span of a week. The client is now ready to start planning for and
practicing positive activities. Those need to be inherently pleasurable,
to provide a sense of accomplishment or mastery, or to be considered
valued actions.

Emphasize how engaging in positive activities has two targets: The pla-
nning phase targets reward anticipation and motivation (or wanting),

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and the practice phase targets response to attainment of reward or

liking. The hedonic impact is facilitated by labeling all of the posi-
tive emotions experienced during the activity. In addition, by keeping
track of their mood before and after each activity, reward learning (i.e.,
learning that by engaging in a specific activity, positive mood increases)
is also targeted.

To begin the planning phase, ask clients to choose three to five positive
activities from their Positive Activity List (Exercise 5.4). The client will
conduct these activities over the next week and will record them on the
Exercise 5.5: Positive Activity Scheduling sheet, with one activity per ex-
ercise sheet. Clients may photocopy this exercise from the workbook or
download multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). The activities, no matter how simple
they may appear, should be broken down into multiple steps, in order to
minimize roadblocks at the time of activation. If the client has difficulties
understanding why to break an activity down into multiple steps, ask
them about skills they have learned in the past, such as learning how
to drive. Did they learn to drive in just one day? No, it required mul-
tiple steps, starting with finding a driving school, signing up for lessons,
learning the theory, daily practices, and so forth. Additionally, breaking
down activities into manageable steps can prevent clients from feeling
overwhelmed. Reassure the client that even completing some of the steps
is valuable. Help the client review and write down on the Exercise 5.5
sheet the steps needed to complete their chosen activities.

Next, clients should identify in which domain an activity falls. For in-
stance, exercising benefits health, and it can also be a leisure activity. If
done with a friend, exercising would be a social activity too. Given the
importance of social connectedness to emotional well-​being, at least one
activity domain should be a social one (i.e., with friends or family).

Ensure that the three to five activities are the right mix in terms of dura-
tion (brief vs. long) and difficulty (easy vs. difficult). If the client reports
already engaging in and enjoying several positive activities, encourage
the addition of activities that lead to a sense of accomplishment, value,
and mastery once completed.

Ask clients to commit to a specific day(s) and time(s) of the week to

do their activity and how much time they will dedicate to it, recording

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that information on the Exercise 5.5 sheet. Encourage the client not to
overschedule as this may lead to feelings of failure.

For clients who are very low functioning, it may initially be more effec-
tive to assign only one easy-​to-​manage activity for practice. Choose an
activity that the client can do repeatedly, such as taking a bubble bath,
reading a book, or making a snack for their children. It is important to
be flexible, particularly in this sensitive early phase of treatment, and
capitalize on the things that the client can do, no matter how simple.
For clients who are highly sensitive to perceived failure, initially choose
“foolproof ” activities.

Finally, remind clients to monitor their mood before and ideally right
after the activity on a scale of 0 for “lowest mood” to 10 “highest mood,”
and label the variety of positive emotions that they experience. Ask them
to keep Exercise 4.2: Positive Emotions Dial handy to facilitate this
process.

Homework for Practicing Positive Activities

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to
complete three to five positive activities each week, recording their
mood before and after and labeling the full array of positive emotions
experienced using Exercise 5.5: Positive Activity Scheduling.

Case Vignettes for Practicing Positive Activities

Case Vignette #1

The following vignette addresses clients who feel guilty about doing
positive activities.

T: Let’s take a look at your Positive Activity Scheduling sheets. How

did it go?

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C: Well . . . I was really only able to complete one activity, and even for
that one, I don’t think I did a good job.
T: What makes you think so?
C: I just have a really hard time doing those exercises. I am not really
sure why, but it just does not feel right.
T: Would you mind elaborating a bit more?
C: Well . . . I am overwhelmed with things I should be doing—​deadlines
at work, stuff at home, school things for the kids, and so on. It does
not feel right to indulge in a rewarding activity while letting other
people down who are waiting for me to get things done!
T: I hear that. Do you feel like your brain is telling you, “The last thing
you have time to do is something enjoyable?”
C: Yes, that is exactly what it is telling me!
T: And when you have this thought, how does this make you feel?
C: Just terrible!
T: And what happens to motivation when we feel terrible?
C: It evaporates. In fact, I didn’t end up getting much done for work and
I even picked up the kids late, because I stayed in bed too long.
T: Does this sound familiar?
C: Yeah . . . The negative mood cycle and downward spiral?
T: That’s exactly right. And how do we break this cycle in this treatment?
C: We do things that make us feel better because then we feel better and
are more motivated to do the other activities?
T: That’s exactly right! Think about the positive activities as an energy
drink or a strong cup of coffee. They make it easier to feel energized
and get started on a challenging task. Even a simple, positive activity
like listening to a fun song or walking in the sunlight for 10 minutes
can improve your mood. And remember the law of inertia: Now you
not only feel better, but you are actually “in motion,” which makes it
easier to keep going.
C: Yes, I guess that makes sense.
T: So how about we look over your list of activities again and see whether
we can improve it. Let’s make sure you have some activities that are
easy to do, and maybe those you could combine with those of mastery
and accomplishment. Can you think of an example?
T: I need to write an email to my daughter’s teacher. Maybe I could play
a fun game with my daughter and then write the email afterward?
C: That sounds like a fantastic example to me!

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Case Vignette #2

This vignette provides an example of how to encourage a client who

does not feel better after doing a positive activity.

C: I completed an activity almost daily, but honestly, they don’t make me

feel better. Sometimes I even feel worse.
T: I am sorry to hear that. Either way, I am glad that you completed the
activities. As we have talked about before, getting started on regular
practices is often the hardest part. You have mastered that this week.
At the same time, we want these activities to make you feel better most
of the time. Let’s take a look at your mood ratings. What do you see?
C: Well, I guess not all of the activities were bad. Some did increase my
mood, but really only slightly. For most, my mood did not change,
and in some, it even got worse.
T: Okay, let’s start with the positive ones. What about them do you think
improved your mood?
C: Hmm . . . I am not sure, but maybe they just felt easier to do? And
also, they felt good right away. Particularly walking along the beach.
T: Great! Let’s make sure we keep those! Now, what about the ones that
did not improve your mood or even made it worse? Did they have
anything in common?
C: Well, I guess some felt a bit scary, and some were just really difficult to
get started on.
T: That’s a great observation. Tell me a bit more about those that felt
scary or were hard to get motivated for.
C: I tried to call a friend I had not spoken to for many years. She is a
really funny person, and I thought that it would be great to reconnect.
I followed the first step and looked up her number, but then when
I wanted to call, I got really worried that she may not want to talk to
me. The thought really distracted me, and I started to feel really bad.
All my motivation was gone, and it just felt like a bad idea to call her.
T: Calling someone you have not been in contact with for a while can
be scary. But like with many things, we just don’t know what will be
the outcome until we give it a try. Unless we try, we just won’t find
out. And, the payoff of feeling good after can be worth it. Do you re-
member what we said about social activities?
C: They boost our mood more than non-​social activities, even if it doesn’t
feel that way going into it.

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T: Exactly. Would you be willing to try calling your friend next week?
C: Umm, I don’t know. I just wouldn’t know what to say.
T: Fair enough. How about we role-​play the conversation?
C: Yes, I think that would be helpful.

Case Vignette #3

This vignette demonstrates troubleshooting with clients who only en-

gage in the same activity.

C: This week, the positive activity was going for a walk in my neighbor-
hood again.
T: How did that go for you?
C: It was okay. Same as the last few weeks. I enjoy it initially because
I get some fresh air and get to move around after a day of sitting at my
desk at work, but it doesn’t improve my mood as much as it used to.
T: Sometimes that can happen if we rely on something too much to boost
our mood. Watching your favorite movie once in a while will prob-
ably improve your mood, but watching it on repeat every day is going
to reduce how much you enjoy it. Variety is key.
C: I understand.
T: What else can you do in addition to walking to boost your mood?
C: Well, I have a lot on my activity list. I can choose something else from
there this week.

Troubleshooting for Practicing Positive Activities

Below we list the common challenges that clients and therapists expe-
rience with positive activities scheduling. Some issues can be directly
addressed by reminding your client of the rationale for engaging in pos-
itive activities, the importance of engaging in several positive activities
throughout the week, breaking them down into steps, encouraging a
variety of activities in a range of difficulties, social involvement, and
quality of reward (hedonic or sense of value, mastery, or accomplish-
ment). Others will require more discussion and support. Those examples
are listed here.

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Activities that involve other people are highly desired and effective but
often very hard for clients to do. Their negative thoughts can get in
the way of their motivation and confidence to reach out to others. For
those clients, role-​playing can be helpful. For instance, a client may have
chosen to call a long-​time friend they have not spoken to for many
months. Breaking the activity down into steps may not be sufficient
(e.g., if the client fears they have nothing to say). The idea is not to turn
the role-​play into an exposure but rather to help the client find a starting
point that will ultimately turn their planned activity into a successful
one. In this example, the client anticipates that it will make them feel
happy to reconnect. Likewise, you can facilitate activities of accomplish-
ment and mastery through role-​playing. Examples include role-​playing
asking for a leadership role at work or asking for help to finish a home
project.

Sometimes clients report that they did not feel better after engaging in
an activity. Examine whether the client was distracted or was ruminating
during the activity. If so, they are unlikely to notice or appreciate the
positive consequences. Here, there is value to remaining “in the mo-
ment” (i.e., mindfulness) when participating in positive activities.
Another reason is that the client completed steps toward a positive ac-
tivity that were not, in and of themselves, reinforcing (e.g., starting to
work on a tax return or work project). In this case, positively reinforce
the client’s behavior and how the client feels progressing toward a given
goal or value (i.e., completing the return or meeting a deadline).

Finally, be mindful of clients engaging in the same activity over and

over. Encourage such clients to engage in different meaningful activities.

Activities of mastery or accomplishment can sometimes make a client

feel anxious. For example, a client plans to complete an overdue project.
While the activity in itself may not be rewarding, the client has deter-
mined that once it is completed, they will feel a sense of accomplish-
ment. Such activities are important and generate positive feelings, such
as pride, resilience, and joy. You should emphasize the goal of accom-
plishment and mastery over the anxiety experienced.

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Savoring the Moment

Following the first week of positive activity practice, you will teach the
skill of Savoring the Moment through memory specificity training for
an activity that the client most strongly associates with positive mood.
Savoring the Moment training involves visualization of assigned activi-
ties, including specific sensations, thoughts, emotions, and situational
details, through the first-​person perspective and present tense. In brief,
the therapist asks a client to recount using the present tense the positive
feelings experienced in a prior week’s activity. This training is designed
to enhance the savoring of reward and to counteract the tendency to dis-
miss positive experiences and overly general memory. Specifically, clients
with depression tend to struggle to generate specific memories that take
place within the span of a single event or day. Without such details, the
positive memory for activities can be impaired. Other memory deficits
include having impoverished positive mental imagery. For instance,
a client may have little problem describing past situations in a script-​
like way but struggles to add emotional attributes, such as feelings and
sensations (e.g., what the forest smelled like, or how the client felt when
seeing their child laughing). Individuals with depression also have a bias
toward a third-​person versus first-​person perspective, which leads to less
positive emotionality. Lastly, clients with depression have difficulty with
valuing positive memories. The successful completion of positive activ-
ities cannot improve a client’s mood if they simultaneously devalue the
experience. Therefore, it is essential to actively recount the memories for
such activities and increase their valuation. Savoring the Moment also
acts as “positive attention training” that directs a client’s attention to
positive features of experiences.

During the Savoring the Moment exercises, clients visualize (prefer-

ably with their eyes closed) and recount, using the present tense, the
moment-​to-​moment details of one of their positive activities, while
highlighting the most positive moments. They are encouraged to visu-
alize their surroundings, the emotions they felt, their physical sensations,
their behaviors and their thoughts. This guided and repeated exercise is
thought to deepen and help clients savor the positive aspects of their ex-
perience. If the client’s attention shifts toward more negative aspects of
an experience, the therapist gently redirects the client’s attention toward
the positive ones. By doing so, clients also learn that they have control

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over their attention and can shift their attention from one aspect of a
situation to another. Research has shown that attention control is an ef-
fective form of emotion regulation (Gross, 1998).

Ask your client to identify an event from a completed Positive Activity

Scheduling exercise sheet. This can be an activity that led to a significant
improvement in their positive mood rating (e.g., from a 4 to an 8). It
can also be an activity they struggled to find positive (their mood rating
stayed the same or even decreased). Next, ask the client to describe the
scene on Exercise 5.6: Savoring the Moment (which can be found in the
client workbook and also in the appendix at the end of this therapist
guide) and rate their current mood on a scale from 0 (lowest mood) to
10 (highest mood). Having the client describe the scene first is helpful
as it provides an overview for the therapist. You can then use this infor-
mation to guide the client to “fast forward” to more relevant details. For
example, when describing a trip to the beach, a client may focus on irrel-
evant details during their recounting, such as the traffic during the drive
to the beach. With the details provided in the overview, you will know
that the majority of positive emotions and sensations occurred when
the client first arrived at the beach, and you can therefore encourage the
client to “fast forward” to this portion of the activity.

After completing the overview and rating their current mood, clients
recount the activity with a focus on the portion of the event that elicited
the strongest increase in positive mood. You can instruct clients who
report no increase in positive mood to recount the event from beginning
to end. You can assist the client in noticing potentially positive emotions
and sensations by asking prompting questions such as, “What positive
emotions do you notice?” and “Where do you feel it in your body?”

In session, clients visualize the scene in present tense. They may prefer to
close their eyes during the recounting. If they do not wish to close their
eyes, instruct them to soften their gaze rather than focusing directly
on you. The goal is to reduce environmental distractions. Choose the
format that makes it easiest for clients to stay in the present moment and
experience the feelings, sensations, and thoughts they are describing. At
every step of the way, remind clients to stay in visual mode, present
tense, and first person whenever you notice the client moving into a
more narrative style or shifting to a different topic.

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Also guide your clients to slow down when they seem to be moving too
quickly, in order to appreciate the moment and the experience. Asking
clients to pause and sit with the physical sensations or emotions they are
having can help deepen their experience of positive emotions as well.
You might nudge your clients to express what they are feeling as they
visualize, using observable cues (such as a smile) to prompt clients to
notice their feelings. The visualization usually takes between five and
10 minutes but can take longer or shorter, and the same exercise can
be repeated. However, we discourage frequent repetition of the same
activity to minimize habituation of positive affect. After completing the
recounting, instruct clients to rate their mood again, to evaluate the
mood-​inducing effects of Savoring the Moment. When guiding clients
through the exercise for the first time, more prompts and interruptions
are allowed. However, once clients repeatedly practice Savoring the
Moment and are aware of how to engage in the exercise, therapists’
prompts and interruptions should be minimal to ensure that clients stay
with the imagery.

For therapists inexperienced in imaginal exercises (e.g., imaginal expo-

sure), it is important for the client to vividly recount the activity along
with the associated positive emotions, physical sensations, and thoughts.
Thus, we encourage clients to close their eyes or soften their gaze, and to
speak in the first person as described earlier. In addition, you may need
to prompt clients to describe particular physical sensations or positive
emotions to deepen their experience. When prompting clients, speak
sparingly and use a soft tone of voice so as not to distract clients from
the imaginal recounting. However, in the beginning, clients may have
difficulty in conducting the imaginal recounting and you may have to
take a more active role (see Case Vignette #1 that follows).

Case Vignettes for Savoring the Moment

Case Vignette #1

This vignette provides an example of how to conduct an imaginal

recounting with a client for the first time. The therapist has to be more

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active to guide the client through the recounting and has to model using
the first-​person perspective. In addition, the therapist directs the client
to repeatedly pause and “sit with” pleasant sensations.

T: As we discussed, the purpose of Savoring the Moment is to train our-

selves to notice even small increases in positive emotions, our physical
sensations and thoughts during activities, and to deepen our experi-
ence of them. Now, I’d like you to recount the event of going to the
beach with your friend Sarah. You mentioned that the biggest in-
crease in your mood happened when you first arrived, right?
C: That’s right.
T: Great. Start there and describe in detail what you were feeling and
thinking. I’ll occasionally ask some questions to help you focus on pos-
itive aspects of the situation. Now, gently close your eyes and begin to
describe first arriving at the beach.
C. So, I was nervous that I wouldn’t have anything interesting to say to
Sarah because I haven’t left my apartment much recently . . .
T: (Softly) Did you notice anything pleasant or positive as you first
arrived?
C: Yes, the sun felt really good.
T: How did it feel on your body?
C: It felt warm.
T: So you are feeling the warmth of the sun . . .
C: I’m feeling the warmth of the sun and how warm the sand feels on my
feet as we step onto the sand. We decide on a place to lay our things
right by the water.
T: (Softly) What are you seeing right now?
C: The water looks so green. It feels nice to be here.
T: And what emotions are you feeling?
C: Relaxed.
T: So you are feeling the warmth of the sun and sand, noticing the green
of the ocean, and feeling relaxed. What happens next?
C: Sarah and I get settled and start talking. She says how nice it is to see
me. I didn’t realize she missed spending time with me.
T: (Softly) What emotions are you feeling when she says this?
C: I don’t know. Happy, I guess. A little sad, too.
T: Where do you feel the emotion of happiness in your body?
C: In my shoulders. I feel lighter.

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T: I’d like you to pause right here and just sit with those sensations.
Really feel them right here in this room. (Pause for 15 seconds.) And
then what do you notice?

Troubleshooting for Savoring the Moment

Some clients struggle with the concept of Savoring the Moment and how
it can lead to improved reward learning. We suggest you use the descrip-
tion from the client workbook:

Why is Savoring the Moment important to do? Savoring a rewarding

experience deepens your appreciation of the activity; it also deepens
your experience of the positive aspects of the activity and the
emotions you felt, which might otherwise be ignored or dismissed.
By recounting the memory, particularly the most positive aspects
of the activity, you are re-​experiencing those positive aspects and
strengthening learning between what you do and how you feel. In
turn, that learning increases interest and preference for other positive
experiences over negative experiences, all of which increases positive
emotions and future involvement in positive activities.

It can be difficult to stay focused, especially in the face of tendencies to

ruminate on past events or worry about future ones. All of this makes
it difficult for clients to engage in an exercise that requires them to stay
in the moment. Remind your client that this is a common struggle for
many people, in the same way that it can be difficult to stay focused
during meditation or yoga. Like those practices, this skill takes a lot of
practice, and yes, clients should expect to get distracted or maybe even
a bit frustrated at first. To facilitate attention during the recounting,
remind clients to focus on the behavioral, emotional, and cognitive
responses to the specific positive experience. Ask clients to describe
in detail what they are experiencing and how they know that they are
experiencing a positive emotion.

As noted above, slow down the process if you notice clients going
through the exercise quickly or in narrative form. This may represent
the tendency to dismiss or disconfirm leaning into the possibility of pos-
itive emotions. This is where you can guide your clients to slow down

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and appreciate the moment and the experience. You might nudge clients
to express what they are feeling as they visualize, using observable cues
(such as a smile) to prompt them to notice their feelings.

Positive body language (e.g., half-​smile, not crossing arms, or open

hands) can further enhance the client’s ability to stay in the moment and
maximize the positive emotions they are experiencing. For clients with
particularly flat affect, it can be helpful to have them watch themselves
discuss their activities with low affect (using a mirror or their cellphone
for recording) and then watch themselves discuss the same activities as
they show more affect (e.g., eyes wide open, smiling), with follow-​up
discussion of how their physical behavior affected their mood.

How can we ensure the emotional recounting exercise strengthens re-

ward sensitivity? One of the best indicators is the mood rating. Did
the client’s mood improve as a result of Savoring the Moment? Another
indicator is the client’s ability to use the present tense when describing
their experience. This is an indicator that they managed to stay in the
moment. The amount of detail of the situation and the use of a range
of positive words are also positive indicators. Clients’ ability to re-​ex-
perience their positive emotions will allow them to remember these
emotions more vividly and intensely.

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CHAPTER 6 Attending to the Positive

(Corresponds to c­ hapter 6 of client workbook)

Materials Needed 84
Goals 84
Summary of Information in Chapter 6 of Client
Workbook 84
Key Concepts 85
Importance of Attending to the Positive 85
Finding the Silver Linings 87
Homework for Finding the Silver Linings 89
Case Vignettes for Finding the Silver Linings 90
Troubleshooting for Finding the Silver Linings 94
Taking Ownership 96
Homework for Taking Ownership 98
Case Vignettes for Taking Ownership 98
Troubleshooting for Taking Ownership 102
Imagining the Positive 103
Homework for Imagining the Positive 104
Case Vignettes for Imagining the Positive 105
Troubleshooting for Imagining the Positive 109
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Materials Needed

■ Exercise 6.1: Finding the Silver Linings (all exercises are included in
the client workbook and also included in the appendix at the end of
this therapist guide)
■ Exercise 6.2: Taking Ownership
■ Exercise 6.3: Imagining the Positive
■ The Imagining the Positive visualization script or audio (the script
can be found in ­chapter 6 of the client workbook and this therapist
guide; the audio file can be accessed at the Treatments That WorkTM
website: www.oxfordclinicalpsych.com/PAT).

Goals

■ Review content from last session and answer any questions.

■ Educate the client on the role of attending to the positive.
■ Introduce the skill of Finding the Silver Linings, facilitate a practice
in session, and assign a practice for homework.
■ Introduce the skill of Taking Ownership, facilitate a practice in ses-
sion, and assign a practice for homework.
■ Introduce the skill of Imagining the Positive, facilitate a practice in
session, and assign a practice for homework.

Summary of Information in Chapter 6 of Client Workbook

■ Individuals with anhedonia report difficulties in (a) noticing positive

aspects of situations, (b) taking ownership over positive outcomes,
and (c) imagining positive outcomes for events.
■ The skill of Finding the Silver Linings helps to train attention toward
positive aspects of situations.
■ The skill of Taking Ownership helps individuals identify contributions
they made toward positive outcomes.
■ The skill of Imagining the Positive improves the ability to imagine
possible positive outcomes.

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■ These practices are introduced to improve positive emotions; they

target liking, wanting, and learning.

Key Concepts

The key concept of this chapter is the introduction of new skills to shift
attention toward positive stimuli, to recognize and reinforce positive
behaviors the client engages in, and to improve prospective positive
mental imagery. It is expected that you will use at least three sessions
to introduce these skills—​one session per practice. Goals for the client
are to:

■ Improve the ability to notice positive stimuli in situations.

■ Improve the ability to recognize and take ownership over behaviors
that have resulted in positive outcomes.
■ Increase the ability to imagine positive outcomes to events.

Importance of Attending to the Positive

The goal of this chapter is to learn to focus attention on positive

experiences through repeated skills training. These skills address deficits
in anticipation of reward by:

1. Having the client notice more of the positive (i.e., sustained attention
to the positive), which helps to anticipate/​prefer positive outcomes
in the future (wanting)
2. Having the client appreciate (appraise stimuli more positively) and
savor the positive, which increases the hedonic experience (liking)
3. Encouraging the client to learn to attribute their own actions to the
positive (learning)

Instead of discounting negative appraisals (as is typical in cognitive re-

structuring), the primary goal of this chapter is to shift attention to
positive features of situations. The underlying assumption is that mood
will become more positive and positive stimuli will become preferred
over negative stimuli, which in turn will encourage further attention
to positive features of experiences. Together this will lead to more posi-
tive appraisals of situations. For example, the skill of Taking Ownership

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encourages clients to recognize ways in which their own behaviors have

contributed to positive outcomes.

The reason for targeting attention is because evidence shows that de-
pressed mood and anhedonia are associated with limited sustained
attention to positive stimuli (i.e., noticing the positive). This is often
observed clinically by a tendency to dismiss positive experiences and to
devote attention and ruminative thinking disproportionately to nega-
tive experiences. This chapter explicitly targets sustained attention to
positive features of past, present, and future experiences.

The focus on past and present experiences is achieved by re-​evaluating

situations that already occurred or are occurring, with effortful recall
and identification of positive features of those events or situations even
when they occurred alongside negative features. This skill, Finding the
Silver Linings, is a direct extension of the work done with Savoring the
Moment of positive activities, wherein again the focus is on positive
features of those events.

Similarly, Taking Ownership involves re-​ examining past or current

situations with positive outcomes, ranging from minor to major, to
identify ways in which the clients themselves contributed to the positive
outcomes.

The skill of Imagining the Positive is about events in the future, and
imagining successful outcomes. Here the goal is to build up the ca-
pacity for prospective positive imagery, which is limited in persons with
depression and anxiety. Importantly, positive imagery training is not to
be confused with positive prophesizing; in other words, the goal is not
to increase the likelihood of positive outcomes but rather to build the
capacity to imagine their occurrence.

As the therapist, you will provide a general introduction to the chapter

by asking clients about their difficulties in attending to the positive, and
explaining what the effects can be on an individual with anhedonia.
You will describe how some people tend to ignore positive events in
their lives, either by not thinking about positive experiences in the past
or by not imagining or anticipating positive events in the future. You
will ask clients if they notice themselves doing this, and if so, how it

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makes them feel. Similarly, you can describe how some people have
difficulty recognizing or appreciating positive events when they occur.
Such individuals may frequently tell themselves that good things never
happen to them, or when positive things do happen, such as receiving
a compliment, the client dismisses these as not genuine or real. Again,
you can ask your clients if they notice themselves doing this, and if so,
how it makes them feel. Using the same description and client self-​re-
flection question, you can describe how some people have no difficulty
recognizing the occurrence of a positive event, but they do have diffi-
culty appreciating it. For example, they might recognize that they are
getting a job promotion, but they do not experience joy from it. Some
people take less ownership of the positive, or fail to take credit for the
good things that happen.

You can then discuss the impact of each of these types of biases on
mood. This will provide the rationale for the “Attending to the Positive”
skill set: recognizing positive events and experiences and taking owner-
ship where possible.

Finding the Silver Linings

To introduce the skill of Finding the Silver Linings, you may ask clients
about the popular phrase “every cloud has a silver lining” and what it
means to them. This phrase means that there are positive aspects to al-
most any situation. However, depression, anxiety, and other negative
emotional states lead people to ignore the positive and focus instead on
the negative. Thus the goal of this skill is to shift attention to the pos-
itive even when there are negative parts of an experience. In other words,
the goal is to look for the positive, big or small, in any situation. You
may give clients a few examples to get the ball rolling: (1) an argument
with a friend that has a good ending, (2) a performance review at work
that includes some areas of weakness and also tips on how to improve,
or (3) feeling anxious at a social event but staying rather than leaving
the situation.

Emphasize that Finding the Silver Linings will have a positive impact on
mood and the client’s likelihood of attending more often to the positive

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in the future. Remind your client that it may seem ridiculous or overly
optimistic to focus on silver linings. This is partly because any new skill
can seem odd at first, but with practice it will become more familiar and
even second nature. And as part of this chapter, remind your client that
they will be purposefully searching for more silver linings than would
be typically expected, in order to develop the skill of attending to the
positive. The notion is that we have to practice any skill more intensely
and more frequently at first in order to develop something that can be
sustained in the long run—​so the skill-​building phase will push Finding
the Silver Linings to the extreme.

You can begin the exercise by asking your client to identify silver linings
for something as simple as brushing their teeth (e.g., my teeth are
healthier, I’m less likely to get cavities, my breath doesn’t smell, people
will be more likely to spend time with me, I’ll have to go to the den-
tist less often, I will save money on root canals, I had a nice taste in my
mouth, and there won’t be something in my teeth to be embarrassed
by). Or, a more complex example could be used—​say, the client’s boss
reviewed a document they had submitted. The document was covered
in red corrections and an entire hour was spent going over potential
revisions. What might be some positives about this event? The client
now knows how to correct the document, and the boss spent a full
hour of time giving corrective feedback to the employee. Now the client
knows the boss’s preferences, and now the boss knows that the employee
can respond to criticisms. This may even improve their training.

If your client demonstrates a good understanding of the skill, ask them

to choose an event that happened to them recently. This event should be
one that was judged to be neutral or negative (although not traumatic;
see later in the chapter). The client should then begin to generate posi-
tive features of this event using Exercise 6.1: Finding the Silver Linings,
which can be found in the client workbook and also in the appendix
at the end of this therapist guide). Clients may photocopy this exercise
from the workbook or download multiple copies at the Treatments
That WorkTM website (www.oxfordclinicalpsych.com/PAT).

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First, have the client rate their current mood state (on the 0-​to-​10 point
mood scale with 0 for “lowest mood” and 10 for “highest mood”). Then
work with the client to identify at least six positive features, being as
creative as needed to generate the list. This can take some time, but is
part of the learning process. Part of what this skill is attempting to ad-
dress is the tendency to give up on identifying positive aspects when it’s
difficult to do so. After generating the silver linings, the client re-rates
their mood and labels their positive emotions. By doing so, learning of
reward is strengthened (i.e., the client learns that by expending effort
to recognize positive aspects of past situations, they feel more positive
emotions).

Remind your client that only after practice will the skills become easier,
more automatic, and even more enjoyable; and, only after considerable
practice will they see a long-​term change in their mood. Should they
indicate that although they did the exercise, they disliked it and did not
notice an improvement in mood, validate this experience for them and
inquire if they are attending to the meaning of what they are writing.
For example, if a silver lining is “I am alive” or “I have shelter,” what
does that mean for them? By prompting more in-​depth meaning, the
exercise will be more effective. You may also ask them to compare it to
how they would feel if these silver linings were not present.

Homework for Finding the Silver Linings

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your client to
complete a Finding the Silver Linings practice each day. They can start
with positive or neutral situations, which may be serious (e.g., visiting
the doctor), silly (e.g., brushing their teeth), or meaningful (e.g., their
child said, “mama”). But clients should eventually practice with more
negative situations.

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Case Vignettes for Finding the Silver Linings

Case Vignette #1

In this vignette, the client is sharing the following types of thoughts in

reaction to the Finding the Silver Linings practice: “What’s the point of
doing this? There was nothing positive in that situation.”

C: For homework, I tried to identify silver linings regarding an argu-

ment that I got into with my coworker last week, but I really don’t
understand the point of doing this. There was nothing positive in that
situation.
T: I understand that the argument you had with your coworker was
upsetting. I also know that practicing this skill of finding silver linings
can be particularly hard to do when we are experiencing a negative
mood state.
C: Yeah, I’m still really worked up about it. Talking about it now is
making me feel pretty down, actually.
T: I can imagine. Being able to identify silver linings is a skill, one that
develops the more we practice. We’ve talked about how our brains
tend to be evolutionarily wired to pay attention to negative aspects of
a situation, and so it is going to take dedicated practice to train our
brains to also pay attention to positive aspects of a situation. When
you find yourself feeling low and having a hard time identifying silver
linings, it is an important signal that you likely need to continue or
increase your practice.
C: I get that, I do. I know I tend to focus a lot on the negative, and
I want to practice finding the positive. It is just hard to find the posi-
tive in something as unpleasant as an argument.
T: I agree that it is challenging to find silver linings with more nega-
tive situations, and it also creates a great opportunity to practice.
I’m curious: Might we try to practice finding the silver lining with
a different unpleasant activity? How about if we focus on something
more neutral, something that we don’t usually think of as having any
positive aspects? What about an activity like brushing your teeth?
C: Well, sure. That’s a pretty tedious activity, but I can try . . . I guess
one positive thing I can think of is that brushing my teeth makes my
breath smell better. It is also good for my long-​term dental health.

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And hmm . . . I guess it also models good hygiene to my children? I’m

always trying to get them to brush their teeth.
T: Those are all excellent silver linings! I think it’s really interesting that
you’ve taken such an everyday activity, like brushing your teeth, and
have already identified several silver linings. Even though brushing
your teeth is not necessarily pleasant or pleasurable in and of itself,
you can identify positive or meaningful outcomes.
C: Yeah, it was nice to acknowledge those things. I guess I can see how
similar silver linings might apply to my argument at work. For ex-
ample, I know that it was important for me to air my grievances with
my coworker, because I didn’t want to suppress my feelings any longer;
it was making me miserable at work.
T: I’m hearing that a silver lining was being able to get that upset off
your chest and out into the open with your coworker.
C: Yes, and it was also important for me to speak up for myself. I don’t
always do that, and I can let things slide when people don’t treat me
nicely. It was good that I advocated for myself, even if it was un-
pleasant to do.
T: This is great work! Let’s continue trying to identify a few more silver
linings about this argument.

Case Vignette #2

The client’s issue in this vignette is that by focusing on the positive,

the client is concerned that the therapist is underestimating or not
acknowledging the enormous challenges in the client’s life.

C: I know you want me to find silver linings in my life, but it is really

hard to focus on the positives right now. I have been feeling really iso-
lated and it is difficult to get through the day being so disconnected
from people during the pandemic. I feel like if I don’t address my
loneliness, it is going to get worse and I will feel even more depressed
than I do right now.
T: I hear that; I know that your loneliness is causing you pain and that
it has been very challenging to feel connected as of late. I don’t want
to discount how hard things have been for you recently or the impor-
tance of connection, but I do want us to take some time to revisit the

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nature of the work we are doing together so that we can be on the

same page as to why we are particularly focused on positive thinking
during this part of treatment.
C: Okay, I think that would be helpful because it feels like we are
ignoring the challenges I’m facing, which really doesn’t feel good.
T: In that case, I’m really glad we are setting aside some time to talk
about this. One reason we are shifting the treatment focus to noticing
the positive is that sometimes we find ourselves in situations where
we can’t change the outcome. For example, even though you started
adding some social activities during the first part of treatment, you
were limited by what you could do because of the pandemic. Given
this reality, it’s important to recognize what positive already exists,
which will give you a change in perspective and then likely a change
in how you feel. Not all of these skills can “fix” the difficult challenges
you may be facing in your life. Instead, we view some of these skills as
being of use as they can help you to better navigate negative emotions
and difficult experiences when they inevitably occur.
C: That makes sense; I guess we don’t expect silver linings to make the dif-
ficult things I’m going through disappear, but rather help me to cope
with those challenges.
T: Absolutely. In fact, Finding the Silver Linings may help you recognize
that you have more social connection than you previously realized,
which may decrease some of those feelings of loneliness. That all being
said, it is important to acknowledge the difficult experiences you’ve
been having that have enormously contributed to your low mood.
And, what you just highlighted is also true. The silver linings skill is
meant to help you identify even just a few positive aspects of the situ-
ation you are facing—​not to ignore or minimize the negative aspects,
but to hopefully bring about more positive thinking, which in turn
can lead to more positive emotions and mood.
C: That’s helpful; I get it.
T: Great. I also want to acknowledge that practicing the silver linings
skill is also helpful to us in the long term. Our brains often get used
to identifying and focusing on negative aspects of a situation, and it
takes a lot of practice to train our brains to increasingly identify and
focus on positive aspects of a given situation as well. Positive thinking
is like a muscle that we want to strengthen over time, and the only
way to do that is through repeated, intentional practice. The more

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we can train our brains to attend to the positive, the more balanced
thinking we can expect to have in the future when we experience
challenging circumstances.
C: I need to remember this—​that even if positive thinking is awkward
or difficult now, it will pay off in the future and eventually feel more
natural.

Case Vignette #3

In this vignette, the client views how well they avoided a situation as an
example of a silver lining, whereas the therapist views the avoidance as
maladaptive.

T: Alright, let’s practice applying silver linings to a somewhat challenging

or negative experience from the past week.
C: Okay, I think we can try with my friend’s Zoom birthday party
I attended. My social anxiety really increased leading up to the party
and got pretty bad during as well.
T: Okay. Taking stock of this Zoom birthday party, can you identify any
silver linings? Any positive aspects of the situation you found your-
self in?
C: Well, my anxiety decreased during the party. I showed up fashionably
late so that I wouldn’t have to deal with the awkward small talk at
the beginning. I also kept myself on mute for most of the party and
didn’t say much. So I guess we can say a silver lining is that I found a
way to keep my anxiety low?
T: I hear that keeping yourself on mute and showing up fashionably late
are both things that were helpful in the short term—​they reduced
your anxiety in the moment—​but with this skill it can actually be
more helpful to focus on the silver linings that took place despite the
fact that you experienced discomfort or anxiety.
C: So you want me to focus on my anxiety?
T: Not quite. I’m curious if we can instead focus on positive aspects of
the situation that arose even though you experienced anxiety leading
up to this event and during the event. This skill is about training our
brains to identify positive aspects of the situation that we may typi-
cally overlook or fail to recognize. For example, it sounds like a silver

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lining was that you ended up going in the first place! You mentioned
feeling anxious before, and even though you showed up late, you even-
tually attended the party. Does that feel like a silver lining from your
perspective?
C: Yeah, I guess the fact that I showed up at all is a positive for sure.
I have been known to “flake” and skip events altogether. It definitely
is a silver lining that I mustered up the confidence to attend.
T: That’s great. Are there any other silver linings that you can think of?
C: I see. . . . Well, a second silver lining is that I kept my promise to
my friend. I RSVP’d yes to the Zoom party and I followed through.
I know it meant a lot to my friend that I showed up, even though
I didn’t say much on the call.
T: Absolutely. These are great. I’m curious if there are any silver linings
from the situation that are positive because of what you learned from
the experience? Or things about your experience that will be helpful
to you moving forward?
C: Let me think . . . You know, I guess I learned that even if I am feeling
anxious, I can get through the whole party without needing to leave
early. Sure, I kept myself on mute and didn’t speak up much, but I got
through it. The anxiety didn’t kill me. I feel like I can be more confi-
dent going to my next Zoom gathering.
T: I think that’s great. I am actually hearing two silver linings: You
learned from this experience that you can get through it, and next
time you will feel more confident to attend.
C: You’re right! There are quite a few silver linings to unpack there.

Troubleshooting for Finding the Silver Linings

One of the most common issues that arise from the practice of Finding
the Silver Linings is perception of invalidation, because from the client’s
perspective, this skill does not address the “real” issues they are facing.
Clients are typically seeking help at the point of peak distress, with a
strong desire to focus on the negative emotional experiences and envi-
ronmental events, to either understand them or fix them. The goal of
the Positive Affect Treatment (PAT) therapist is to balance validation
of the client’s distress and undesirable life circumstances with the value
of improving mood through attending to the positive; by attending to

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the positive, the occurrence or impact of negative emotions or negative

events will be lessened, and the client will be in a better “emotional
place” to more effectively manage their negative emotions or negative
events. It is also an opportunity for you to reinforce the notion that the
pull of negativity is the very thing that is being targeted by this treat-
ment strategy—​for the client to learn to shift away from negativity and
toward positivity.

You can inform clients that there may be occasions of frustration be-
cause you will continually refocus their attention onto the positive even
though the client is drawn to discuss negative experiences. Being overly
drawn to the negative is the very thing that is being targeted by this
treatment, so you can validate the pull of negative events, the negative
impact of staying on the negative, and the value of emotion regula-
tion through shifting attention. In essence, you will reassure the client
that negative emotions and negative events are significant in their lives,
and that directly targeting the negativity is not the only (nor the best)
way to find relief; instead, this treatment builds positive capacity so
that negative emotions and events fade in significance or become more
manageable.

You can validate that it might feel strange, unfamiliar, or even risky to
ignore the negative experiences, but nonetheless encourage clients to ex-
periment with evaluating the power of refocusing their attention on the
positive, even in the midst of negative events. The benefit from attending
to the positive will depend on how much clients lean into these skills,
since the pull to focus on the negative may continually tug them away.
In these cases, the notion of training can be helpful—​training to build
up the muscle of positivity to be stronger than the muscle of negativity.
There may be occasions when, even though the client has agreed to the
therapeutic rationale, they continue to focus on the negative. You can
validate the client and then remind them of the treatment rationale.

Sometimes clients indicate that they cannot think of even one posi-
tive feature of a situation. In this case, you can validate the difficulty of
generating positive features particularly when we are in a negative mood
state, and then restate the skill-​building aspect of this treatment, and
the very fact that the difficulty identifying positive features indicates
that this approach is the right one. Then, start with a silly or mundane

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practice such as identifying positive features of brushing one’s teeth, cut-

ting finger nails, or yawning.

There will be some events in the client’s history for which the skill of
Finding the Silver Linings is not appropriate—​specifically, traumatic
events. Talking about trauma can trigger appropriately intense emotions
and is beyond the scope of this particular attention skill. While some
people can find meaning and growth following trauma, that typically
involves more extensive work with trauma-​focused treatments. Hence,
we do not encourage applying Finding the Silver Linings to traumatic
experiences, at least not in the absence of prior prolonged exposure or
cognitive processing therapy around the trauma.

Another concern that can arise is when clients escape a situation due to
panic, anxiety, or overwhelming distress. In these cases, steer the client
away from considering avoidance as a positive and attempt to identify
other positive features of the situation (e.g., the client entered the situ-
ation even though anxious, learned what to do differently next time).

Finally, some clients may report that they have no problem attending to
the positive. In those cases, it is possible to skip this chapter, but we gen-
erally recommend continuing with the chapter regardless, since clients
may discover biases toward the negative or room for improvement as
they proceed.

Taking Ownership

The next skill in this chapter, Taking Ownership, teaches the client to
take credit for ways in which they contribute to positive outcomes. This
skill specifically targets reward learning, or realizing that by one’s own
actions, rewards can be achieved. Taking credit where due is a relevant
skill since depression and anhedonia are associated with a biased at-
tributional style, whereby negative outcomes are attributed to oneself
and positive outcomes are attributed to others or other circumstances.
Diminishing self-​attribution for positive outcomes not only limits the
learning of reward (i.e., “if I do this behavior, I will be likely to get
that positive outcome”) but also reduces the motivation to engage in
behaviors likely to lead to reward in the future.

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Begin this section by informing your client that it is common for people
to have difficulties seeing how their behavior produces good things
for them. For example, if a situation or event goes well, an individual
might attribute the positive outcome to luck rather than to their own
contribution. Ask your client if this resonates with them. Then discuss
the impact of this attributional bias—​specifically, that failing to rec-
ognize how our behavior contributes to a positive event decreases the
likelihood that we will engage in the same behaviors in the future, even
though the behaviors make events more positive. This is because our
memory of events and past behavior becomes a blueprint for future
events. Knowing how our behavior contributed to a positive event will
reinforce that behavior and lead to more positive events in the future.
Moreover, it will contribute to the anticipation and motivation to do
other behaviors that may lead to positive outcomes. That is because the
sense of control engendered by knowing that we can contribute to the
likelihood of a positive outcome motivates behavior in that direction.
Taking Ownership of positive events occurring in our lives is just as im-
portant as noticing that these positive events exist. Before we can create
positive events in our lives, we first must believe that we can affect and
influence certain positive things.

You can then lead a practice with the client by identifying a positive
event that has occurred in the relatively recent past (e.g., showing up
for therapy, having an enjoyable time with a friend, volunteering) and
asking the client to identify and highlight what their contributions were
to the event, using Exercise 6.2: Taking Ownership, which can be found
in the client workbook and also in the appendix at the end of this ther-
apist guide. Completing this exercise may take time, but it is impor-
tant to persist, be creative, and identify even the most minor ways in
which the client may have contributed to an outcome. Next, it can be
helpful to have the client to “sit with” (or reflect upon and appreciate)
Taking Ownership of the positive outcomes. This can be done by writing
out and then verbally stating out loud what their contributions were
as they look in the mirror. The goal here is to deepen the client’s ex-
perience of reward. You may encourage your client to show positive
body movements (e.g., smile) as they verbally state out loud their own
contributions. After reading out loud, they can then sit quietly and re-
flect on their contribution. Next, ask your client to re-​rate their mood
and label their emotional response to deepen the emotional experience

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and learn reward (i.e., “by reflecting on my contributions to positive

events, my mood is more positive”).

Homework for Taking Ownership

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your client to
complete one Taking Ownership exercise each day.

Case Vignettes for Taking Ownership

Case Vignette #1

The client’s issue is that they don’t feel as if they deserve any credit for a
positive outcome because they are not worthy.

T: Let’s practice identifying how you contributed to a positive event that

occurred in the past week. Is there something good that happened that
you can think of as an example?
C: I had a nice dinner with my family last night, but I don’t really see
how I had anything to do with that.
T: Tell me about that.
C: As I mentioned, I’ve been feeling pretty down on myself lately because
I’ve hardly been able to keep up with work and taking care of the
kids. If anything, I feel like it’s my fault that things go wrong all the
time and my house is a mess.
T: Yes, you certainly have a lot on your plate right now. Do you often
find yourself taking all the blame when things go wrong?
C: All the time. I feel like I can’t do anything right.
T: And what about when something goes well? Do you “blame” yourself
for positive things, too?
C: No, of course not. I don’t deserve the credit.
T: It’s common for people to take all of the ownership for bad things and
none for good things. If you think about it, it’s really quite unfair! The
purpose of this skill is to balance out that tendency by training our
brains to notice when we contribute to positive events in our lives. It

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may feel challenging at first, but with practice it will become easier
and can help improve the way you feel about yourself.
C: When you put it that way, I guess it is lopsided for me to do that to
myself. I can’t help but feel pretty worthless, though.
T: Would you be willing to give it a try? Let’s return to the nice dinner
you had last night. What did you do that led to having dinner? For
example, did you make these plans?
C: Well, I have to put dinner on the table every night for my kids. So yes,
I made pasta for them.
T: Great! So one major contribution is that you cooked the meal. What
were all of the steps that went into that? Did the water boil itself?
C: I guess you’re right: I did have to think ahead by going grocery shop-
ping, assembling the ingredients for my kids’ favorite pasta sauce, and
making a salad.
T: Wow, I heard you just come up with three more things you did to
contribute to the dinner. Another part of what I’m hearing is that you
were quite thoughtful and even anticipated what your kids would
like to eat. Do you think that being a caring mother and listening to
your kids’ preferences in the past contributed to the nice dinner, too?
Let’s see if we can come up with a few more things to add-​and really
build this muscle.
C: Yeah, I guess I’m a better mom than I give myself credit for. I also
invited over my sister because I know the kids always love seeing her.
We were all laughing together. I’m surprised I was able to come up
with a few things. In my mind it was just another night, but breaking
it down like this helps me see all the little things that I did to make it
happen.
T: You’re exactly right. It is very easy to discount these experiences by
glossing over them. But it seems like your efforts positively impacted
your family members, who I know you really care about.

Case Vignette #2

In this vignette, the client is not comfortable accepting ownership and

fears being judged for doing so.

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C: I don’t like talking about the things I did well. Won’t getting too good
at this skill make me arrogant?
T: I hear your concern and want to understand more. Where did you
learn that taking ownership for your contributions would mean you
are arrogant?
C: I guess it’s always been a part of my family values. My parents taught
me that no one is better than anyone else and it’s conceited to brag
about your accomplishments. If they saw me talking this way they’d
probably call me on it.
T: I think it is important to distinguish between excessively bragging
to other people versus noticing for yourself what you contributed to
positive events, which is the focus of this skill. Do you see a differ-
ence there?
C: It makes sense that it doesn’t necessarily mean rubbing it in other
people’s faces or comparing to other people. But why would it be
helpful to notice what I do well for just myself?
T: Good question! A lot of people with low mood tend to ignore their role
when good things happen, which can lower their mood even further
and contribute to a sense of powerlessness. Further, not taking respon-
sibility for the positive things in our lives reduces the likelihood of pos-
itive events happening in the future. Why do you think that might be?
C: I’m not sure. When good things happen, I feel like it was random or
I just got lucky. Maybe realizing my contribution could help me feel
more in control?
T: Exactly! Disregarding our contributions can decrease the chances of
positive things happening again because we never learn how to gen-
erate them. On the flip side, recognizing our contributions can help
us do more of what was effective, in order to increase the chances that
positive outcomes will happen in the future.
C: Okay, I get it now and can give it a try even though it feels weird.
T: Great! Like all new skills in this treatment or in life, it might feel un-
comfortable at first but will become easier with practice. Let’s think
through this with an example.

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Case Vignette #3

In this situation, the client fears that feeling positive emotions about
their contributions will lead to complacency. They do not allow them-
selves to feel positively due to a belief about what they “should” be doing
as their duty.

C: If I pat myself on the back all the time, won’t I become complacent?
I’m afraid I’ll become even less motivated to do schoolwork because
anxiety is one of the only things that drives me.
T: I know you’ve talked about how important your academic goals are
to you, like getting good grades and graduating from college. It sounds
like anxiety, along with a fear of failure and self-​critical thoughts, can
be a motivator in the short term. However, how does being driven by
worry affect your energy and motivation in the long term?
C: I’m drained all the time and after the adrenaline rush ends, I crash.
But I’m afraid to be too relaxed or too positive.
T: Would you be willing to try out the skill this week? We can treat
it like an experiment to test out whether taking ownership of your
contributions does indeed affect your motivation. In fact, positive
emotions—​such as feeling accomplished, proud, and excited—​can
often energize us to do more, especially in the future.
C: I’m willing to try it. I just don’t like the idea of feeling good about
myself for things I should be doing anyway. Because my parents are
paying for college, being a good student is my duty. I don’t have the
right to feel proud of myself.
T: I’m glad you shared that with me; “should” thoughts can cause us to be
really hard on ourselves. Let’s imagine one of your friends from college.
Do you judge them for feeling proud of themselves after they do well
on an exam?
C: No. I feel happy for them and want my friends to feel good.
T: I’m hearing that when someone shares their accomplishments with
you, you even feel positive emotions too! Why do you think it might
be helpful for your friends to feel proud of themselves for studying in
order to do well on an exam?
C: Because it’s like positive reinforcement, right? Then my friends would
be rewarded and might feel more motivated to study in the future.

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T: Exactly! What would it be like to apply this same logic to yourself?

Let’s try out an example by identifying your contributions to a positive
event that happened this week.
C: I did really well on my biology midterm earlier this week. I made
flashcards to help me study. I got a 90%—​but I can’t help but dwell
on the 10% I got wrong.
T: Great job identifying that you put in the effort to make flashcards! I’m
also impressed that you’re noticing the natural tendency for our minds
to drift to the negative. I’m not suggesting that you should ignore
your mistakes or room for improvement. Instead, I wonder whether
it could be equally important to really understand what you did that
contributed to the 90% you got right. This skill of Taking Ownership
trains our brains to also focus on our own positive behavior.
C: That makes me feel better that I don’t have to ignore what I got
wrong, but that it’s more about balancing out what I focus on.

Troubleshooting for Taking Ownership

For some clients, identifying the positive event may be the hardest part.
Validate this, and emphasize that identifying positive events in one’s life
is another important skill to practice. For clients who report that they do
not have any positive experiences in their lives, you may include their ac-
tivities that were completed as part of their Positive Activity Scheduling
(Exercise 5.5). Or, you may also ask the client what behaviors they had
to do in order to come to the session today.

The natural tendency of anhedonia and depressed mood is to dismiss

positivity, including the ways in which one may have contributed to
positive outcomes. Encourage clients to lean into the reflection of own-
ership—​to deeply reflect upon how their own actions contributed to
certain positive outcomes.

Occasionally, fear of expressing positive contributions may emerge when

clients worry about being judged negatively by others for assuming a
role they don’t feel they deserve. They may worry that they are irre-
sponsibly ignoring negative emotions or negative events. Again, balance
validation of those feelings with the fact that they represent the pull of
negativity, and the value of learning to weaken that pull is by focusing
instead on positive elements.

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Clients’ doubts about this skill may emerge in comments that it has only
a limited value in the larger picture of their negative life experiences (i.e.,
“How does accepting my small contributions matter when I have so
much going wrong in my life?”). Here, you can validate these concerns,
but re-​emphasize that building positive capacity will enable the client to
be less overwhelmed and more able to cope with negative parts of life.

Imagining the Positive

The last skill covered in this chapter is Imagining the Positive, which
targets the anticipation and motivation for reward as well as savoring the
attainment of reward, with secondary effects upon learning of reward
by having clients rate their mood before and after each exercise. This set
of exercises targets the impoverished positive mental imagery (Holmes
et al., 2016) and bias to interpret ambiguous information negatively
(Rude et al., 2002) that characterize depression and anhedonia.

Introduce this topic by exploring whether clients have difficulty

envisioning or anticipating future events going well for them and in-
stead assume that future events will go poorly. You can then explore
the consequences of anticipating negative outcomes. Imagination can
be a blueprint for future behavior. Imagining a situation going well
can teach and prepare an individual to respond in a way that enhances
the likelihood of that event going well (although this skill will not
guarantee positive outcomes and should not be confused with simple
prophesizing). Since the evidence suggests that mood is more likely to
be boosted with greater vividness of the visualization, encourage clients
to use all of their senses in this skill (sight, hearing, smell, taste, and
touch/​temperature).

Ask your client to identify an event that is expected to occur in the next
week. Examples might include going to the next treatment appointment,
meeting a friend, or presenting at work. Using Exercise 6.3: Imagining
the Positive, which can be found in the client workbook and also in the
appendix at the end of this therapist guide, clients write about the sit-
uation going well for them prior to starting the visualization as an aid.
Some clients find it difficult to begin a visualization without writing out
the future event more positively first.

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Then engage your client in a visualization, which has similarities to

Savoring the Moment. Using the following steps, guide your client
through a visualization of their future situation going well, with the
client sharing out loud the events in present tense:

■ Remind them to use all of their senses and that they should envision
the situation positively.
■ Inform them that they might notice a tendency or urge to imagine
the situation negatively, but request that they do their best to push
themselves toward the positive.
■ Have them think of a starting point for themselves (e.g., a few
minutes before the event or when the event starts).
■ Have them walk slowly through the future event, in present tense as
it unfolds in front of their eyes.
■ Stop frequently to encourage your client to describe thoughts,
emotions, and physical sensations they are experiencing.
■ Ask them to rate their mood on the exercise form before and after
the visualization.

After the visualization, guide the client to process how they felt im-
agining the situation and reinforce changes in their mood as a result of
the visualization. Reinforce labeling of a variety of positive emotions
such as joy, excitement, curiosity, and happiness. If your client has diffi-
culty identifying positive emotions, encourage them to describe how it
feels in their body to have a particular emotion (e.g., feeling lighter or
warmer) or use labels from Exercise 6.3: Imagining the Positive.

Box 6.1 provides an example of a visualization script for Imagining the

Positive that can be used for homework; note that a recording of this
script is available for both your clients and you on the Treatments That
WorkTM website (www.oxfordclinicalpsych.com/PAT).

Homework for Imagining the Positive

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to
complete a visualization of a positive future event each day over the

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Box 6.1 Visualization Script for Imagining the Positive

Gently get yourself into a comfortable position with your feet flat on the ground, your back
upright but not too stiff, and hands in your lap. If you feel comfortable, gently close your eyes
or rest them on a spot in front of you. Bring to mind an image of your surroundings at your
starting point.
Imagine where you are as vividly as possible. Notice what you see around
you . . . smells . . . sounds . . . temperature. Do you notice a nice aroma? Do you notice sounds
of nature or other noises? Is it warm or cool? Do you feel a nice breeze? Take a moment to notice
your surroundings. (Pause)
Now shift your attention to your own body in that future moment. What are the physical
symptoms you are feeling? Are you feeling a rush of adrenaline? A release of tension? Perhaps a
positive racing of the heart or a smile on your face? (Pause)
What are the emotions you are feeling? Excitement? Peace? Joy? Curiosity? Compassion? Interest?
Imagine feeling one of these positive feelings and what it might feel like in your body. (Pause)
Now identify your thoughts in this future context. How can you make them more positive?
(Pause)
Begin to slowly walk yourself through the events that you wrote down on your exercise form. Take
time to notice your positive thoughts, emotions, and bodily sensations as you walk yourself through
those positive events. (Pause)
Notice what your future self would be feeling now . . . thinking now . . . (Allow minutes to pass)
Whenever you are ready, gently bring your attention back to the room, and open your eyes.

next week, with each practice lasting at least five minutes. Clients can
practice by listening to the audio, reading the script, imagining without
using any aid, or recording and listening to themselves read the script.

Case Vignettes for Imagining the Positive

Case Vignette #1

This vignette is an example of how to encourage clients to imagine posi-

tive future events if they do not believe positive things will happen.

T: Let’s try to imagine a positive event that could happen in the future.
C: I don’t think that this is going to be helpful for me.
T: Tell me more about that.

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C: I don’t think anything positive is going to happen to me in the fu-

ture. Things have felt so hard for so long, and I don’t really experience
anything positive in my day-​to-​day life. Why would I imagine some-
thing I don’t think is going to happen? More than that, why would
imagining something even help me?
T: It can be hard to imagine positive things happening in the future
when you’ve been experiencing a low mood for so long. As we’ve
discussed previously, mood and thoughts are connected, and when
people are in a low mood, it is much harder to think about positive
things that may happen in life. That being said, we have found that
by attending to the positive, mood becomes more positive.
C: Okay.
T: Attending to the positive is like strengthening a muscle. How do you
gain strength?
C: Training or practice?
T: Exactly. Imagining the positive is a way to give your brain practice in
attending to the positive. The more you imagine the positive, the more
we expect that you will notice improvements in your mood. Would
you be willing to brainstorm some positive things that might happen
in the future?
C: I guess, but like I said, I really can’t think of anything.
T: I wonder if it might be helpful to turn back to the positive activity list
we made at the start of treatment.
C: Okay.
T: Looking at that list, are there any positive events you wrote down that
you could imagine happening in the future?
C: Well, I wrote down “spend time with my daughter.” She lives far
away, and I don’t see her often, so I’m not sure it would ever happen.
T: Great work identifying a positive event. It sounds like seeing your
daughter, or going on a trip to visit her, could be a positive and very
meaningful experience for you. This skill is all about imagining a pos-
itive thing that could happen, so it’s okay if you aren’t sure if it would
happen. Are you willing to walk through this event with me as if it
were playing out in real time?
C: Yes, I can try it.

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Case Vignette #2

This vignette is an example of how to encourage clients to imagine pos-

itive future events if they have other major life stressors.

T: Today I want to talk through a new skill that we call Imagining the
Positive.
C: Okay.
T: Imagining the Positive is another form of attending to the positive.
We generally find that when people are able to imagine positive things
happening in the future, their mood becomes more positive.
C: It feels kind of like you’re telling me that simply thinking about pos-
itive things happening in the future is going to make everything
better. That seems a little short-​sighted to me. . . . I have so many real
problems in my life; in what world is Imagining the Positive going to
improve the fact that I am chronically ill, working full time to try to
make ends meet and take care of my kids, and feeling like I don’t have
any friends or family to support me right now?
T: I hear you. And you know what? You’re right. You are juggling so
much right now. Imagining the Positive isn’t going to fix all of those
real problems. But Imagining the Positive is one skill that we can add
to your toolbox. The overarching goal here is to find ways to appre-
ciate and experience positive events more deeply. Can you think of any
ways that Imagining the Positive might be beneficial to your life?
C: I guess I’m often focused on which bad thing is going to happen, so if
I wasn’t thinking about that all of the time, maybe I’d feel better.
T: I think that’s a great point. It sounds like you’ve experienced the ways
that anticipating the negative might actually make you feel worse. So,
it’s possible that focusing on the positive could make you feel better!
C: Yes, I guess it could help in some ways.
T: What do you think life might look like for you if you were able to
more automatically appreciate and experience the positive?
C: I mean, I’d like to think that maybe if I was expecting good things to
happen, I’d be doing more in general. Maybe I’d try to see friends or
do new activities.
T: I’ve heard you say now that maybe life might look a little different
if you were able to more automatically think about, anticipate, and
savor the positive. Again, I’m not saying that this skill will take away
all of the challenging things in your life. However, I’m wondering

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if, given that this has the chance to boost your mood, you might be
willing to give this skill a try?
C: Yes, I’m open to trying it.

Case Vignette #3

This vignette demonstrates the process of using Imagining the Positive

with clients who state that the skill makes them feel worse.

T: Let’s imagine a positive event that could happen in the future. I’d like
you to walk me through this event in present tense, describing any
emotions and physical sensations that arise in the moment. This is
similar to what we did in our first sessions, but instead of recounting
something you’ve already done, we will focus on something positive
that could happen in the future. Do you have an idea of an event we
could use for this exercise?
C: Yes. I really used to like traveling and I have always wanted to go to
Paris with my daughter and show her the Notre Dame.
T: Great! Why don’t you start by telling me what you see when you im-
agine being in Paris with your daughter, looking at the Notre Dame?
C: Well, I am excited to finally be here with her. I am holding my
daughter’s hand while I point to the gargoyles on the building’s ex-
terior. My daughter thinks they look funny and laughs. I walk with
my daughter around the perimeter of the building and tell her about
the big fire that happened. I’m starting to feel melancholy in this mo-
ment. I had been to Paris years ago when I studied abroad. I was so
full of energy and joy and adventurousness. Now, I feel like I’ve lost
that spark. I feel like the world I’m showing my daughter is darker
and sadder. (Client becomes tearful.)
T: It makes perfect sense to feel saddened by the ways life and the world
has changed since you first saw the Notre Dame when you were
younger. I do want to take a moment to notice the ways your mind is
being pulled to the negative in this situation. I am wondering if you
might be able to return to this moment with your daughter and con-
tinue to imagine the positive emotions and sensations that could arise
in this situation?

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C: I’m sorry, but I just don’t know if I can keep doing this. I know this
is supposed to make me feel better, but I just feel worse after realizing
how off course I am from where I hoped to be.
T: I hear that this has been a painful exercise for you. I want to remind
you that this is a skill to learn and practice. It can feel very chal-
lenging at first. However, the only way to get better at something like
this is to keep practicing. We’ve talked in the past about how doing
these exercises is similar to weight training. Continued practice with
the skill will strengthen your brain’s ability to imagine the positive
and to savor that experience. Do you think your mood could look dif-
ferent if you were able to imagine the positive more easily?
C: I guess it might. Maybe I’d just be less pessimistic overall. I wouldn’t
always be expecting the worst scenario. Is it possible that thinking
good things might happen could lead to more positivity? I’m not really
sure . . .
T: I think you’re exactly right. We often find that when people are
able to use this skill, they are more motivated to engage in activi-
ties that produce positive outcomes. When positive outcomes do occur,
practicing these skills often enables people to really savor the positive
aspects of experiences more thoroughly, which tends to increase posi-
tive emotions.
C: That makes sense.
T: I’m wondering if now, after reminding yourself why this activity
could help, you might be willing to return to our exercise and try to
keep your attention focused on the positive?
C: Yes, it might be hard, but I think I can do that.
T: Wonderful. So, you’re outside of the Notre Dame with your
daughter . . .

Troubleshooting for Imagining the Positive

For clients who report difficulty identifying positive future events, they
can choose a past activity from Positive Activity Scheduling (Exercise 5.5)
and imagine that it’s an upcoming future activity.

Some clients may find this skill invalidating, given their dire life
circumstances. In this case, validate their life circumstances, and at the

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same time remind them that the goal of this chapter is not to change
their life conditions but to rebalance mood in a more positive direc-
tion, and that by so doing, life circumstances will be more effectively
managed.

Finally, some clients may find the exercise induces negative emotions
and rumination since the contrast reminds them of what they do not
have. In this case, you can again validate, and at the same time, remind
clients that the skill of being able to imagine positive future events is
designed to build the muscle for positivity. This skill will eventually lead
clients to be more motivated to engage in behaviors that will be more
likely to lead to positive outcomes and to savor such outcomes when
they do occur, which will in turn contribute to positive emotions and
lessen negative emotions.

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CHAPTER 7 Building Positivity

(Corresponds to c­ hapter 7 of client workbook)

Materials Needed 112

Goals 112
Summary of Information in Chapter 7 of Client
Workbook 113
Key Concepts 113
Importance of Building Positivity 114
Practicing Loving-​Kindness 115
Homework for Practicing Loving-​Kindness 119
Case Vignettes for Practicing Loving-​Kindness 119
Troubleshooting for Practicing Loving-​Kindness 122
Practicing Gratitude 123
Homework for Practicing Gratitude 125
Case Vignettes for Practicing Gratitude 125
Troubleshooting for Practicing Gratitude 130
Practicing Generosity 131
Homework for Practicing Generosity 132
Case Vignettes for Practicing Generosity 133
Troubleshooting for Practicing Generosity 136
Practicing Appreciative Joy 136
Homework for Practicing Appreciative Joy 139
12

Case Vignettes for Practicing Appreciative Joy 139

Troubleshooting for Practicing Appreciative Joy 142

Materials Needed

■ Electronic device to play audio (optional)

■ Exercise 7.1: Loving-​Kindness (all exercises are included in the client
workbook and also included in the appendix at the end of this ther-
apist guide)
■ The guided instructions for practicing Loving-​Kindness script or
audio (the script can be found in c­ hapter 7 of the client workbook and
this therapist guide; the audio file can be accessed at the Treatments
That WorkTM website: www.oxfordclinicalpsych.com/PAT).
■ Exercise 7.2: Gratitude
■ Exercise 7.3: Generosity
■ Exercise 7.4: Appreciative Joy
■ The guided instructions for practicing Appreciative Joy script or
audio (the script can be found in c­ hapter 7 of the client workbook and
this therapist guide; the audio file can be accessed at the Treatments
That WorkTM website: www.oxfordclinicalpsych.com/PAT).

Goals

■ Review content from last session and answer any questions.

■ Explain the science that supports the four positive practices
introduced in this chapter.
■ Introduce Loving-​Kindness, lead a practice in Loving-​Kindness, and
assign Loving-​Kindness practice for homework.
■ Introduce the benefits of Gratitude, lead a Gratitude exercise, and
assign Gratitude homework.
■ Introduce the benefits of Generosity and assign Generosity homework.
■ Introduce Appreciative Joy, lead a practice in Appreciative Joy, and as-
sign Appreciative Joy practice for homework.
■ Review key concepts from this chapter.

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Summary of Information in Chapter 7 of Client Workbook

■ Loving-​Kindness is a practice, where one visualizes a living being or

the world, to which loving and kind thoughts are offered. It has
been shown to improve one’s mental health and well-​being, as well
as feelings of connectedness.
■ Gratitude is an emotion, behavior, and thought strategy. When used
regularly as a skill, it has been shown to result in many positive
mental health benefits.
■ Generosity is the act of giving by choice, and it is limitless if defined
creatively. Regularly practicing Generosity can result in increased
happiness and can reduce the effect of negative outcomes on mood.
■ Appreciative Joy is the experience of positive emotions that emerge
from the success of others. It is also the practice of offering positive
thoughts of continued good fortune to another. It can improve pos-
itive affect, like the other positive practices.

Key Concepts

The key concepts of this chapter are building positivity through four
new skills that have been practiced for centuries and demonstrated by
research to increase positive emotions. We expect that you will use at
least four sessions to introduce these skills—​one session per skill. Clients
will learn how to practice Loving-​Kindness and Appreciative Joy to gen-
erate feelings of love, joy, and connection. They will also learn how to
apply the skills of Generosity and Gratitude to their daily lives. Goals for
the client are to:

■ Begin a practice of Loving-​Kindness.

■ Incorporate daily acts of Gratitude.
■ Build acts of Generosity into their week.
■ Experiment with a practice of Appreciative Joy.

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Importance of Building Positivity

In this chapter, you will introduce four skills: Loving-​Kindness, Gratitude,

Generosity, and Appreciative Joy. What is key to emphasize here is that
centuries of cultural practice and an abundance of research demon-
strate the positive effects of these skills or practices on one’s mental
health, well-​being, and relationships (Algoe & Haidt, 2009; DeShea,
2003; Emmons & McCullough, 2003; McCullough et al., 2002; Van
Overwalle et al., 1995; Wood et al., 2008b). Unfortunately, these skills
are often misunderstood because of their vague or multiple descriptions.
Therefore, describing and practicing these skills in session with the client
will be essential. This applies even to Gratitude and Generosity, which are
universal human experiences.

It is important for you to review the science and history behind each
of these concepts with your clients. This can be done by dedicating a
separate session to each positive practice, which is the recommended
option. Each session begins with a review of homework from the prior
session, followed by an introduction of the science and history of the
next “Building Positivity” skills. Then you will lead a practice of the
exercise, followed by a discussion of the client’s experience. At the
end of session, there is another review of the session’s content and
assigning of homework. Another option is to review all of the science
and history of these skills in a single session before dedicating addi-
tional sessions to the practice of these exercises.

The order of how to introduce these positive practices is up to you

as the therapist; however, as indicated in the workbook, we recom-
mend the following order: Loving-​Kindness, Gratitude, Generosity,
and Appreciative Joy. There are multiple reasons for this. It can be
beneficial to start with the skill of Loving-​Kindness, which sometimes
requires extra time and practice for its benefits to surface. Also, a
feeling of Gratitude (the next recommended skill) is often cultivated
during this practice. Research has shown that Gratitude predicts pro-
social behavior, like Generosity (Emmons & McCullough, 2003),
which is the next skill we suggest covering. Finally, acts of Generosity
provide fantastic situations with which to practice Appreciative Joy—​
the final skill.

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Practicing Loving-​Kindness

Background

Loving-​Kindness began as an Eastern spiritual practice and has been

gaining more prominence in the West as a secular practice. It involves
focusing one’s awareness on loving and kind concern for other living
beings, oneself, and the world (Hofmann et al., 2011). It has also
been described as an act of training one’s emotional experience toward
warmth and tenderness, using an open orientation (Garland et al.,
2010). During a practice, one visualizes a living being or the world, to
which loving and kind thoughts are offered. There is a mindful aware-
ness of thoughts, emotions, and sensations that arise.

Loving-​Kindness interventions have been shown to increase positive affect

(Fredrickson et al., 2008; Hutcherson et al., 2008; Zeng et al., 2015) and
decrease negative affect (Hutcherson et al., 2008), including anger, pain,
and distress (Carson et al., 2005). Some research suggests that Loving-​
Kindness meditation reduces anhedonia as a negative symptom of schiz-
ophrenia (Johnson et al., 2009). This practice has also been shown to
increase feelings of connection to others (Hutcherson et al., 2008).

In PAT, we use Loving-​Kindness to target reward attainment, or liking.

Through a Loving-​Kindness practice, one notices and appreciates
loving and kind emotions, thoughts, and physical symptoms. Koole
and colleagues (1999) demonstrated that self-​affirmations following
failure led to less rumination and increased positive affect, suggesting
that Loving-​Kindness toward oneself may lead to changes in negative
thinking, which results in increased positive affect. Further, Fredrickson
and colleagues (2008) found that increases in positive emotions fol-
lowing Loving-​Kindness predicted change in resources, which was asso-
ciated with change in life satisfaction.

How to Practice Loving-​Kindness

You will lead the client through a Loving-​Kindness exercise in session by

reading the guided instructions script in Box 7.1 or playing the audio.

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Ensure that the client records their mood beforehand using the Exercise
7.1: Loving-​Kindness form, which can be found in the client workbook
and also in the appendix at the end of this therapist guide. A recording
of the script is available for both you and your clients on the Treatments
That WorkTM website (www.oxfordclinicalpsych.com/PAT), and clients
may photocopy this exercise from the workbook or download multiple
copies from the website.

Box 7.1 Guided Instructions for Practicing Loving-​Kindness

Find a comfortable position someplace with little to no distractions. It can be helpful to sit in a
chair with your feet flat on the ground, your back upright, and your eyes closed or gently resting
on a spot in front of you.
If you notice that your mind is racing, wandering, or being especially distractible today, take
a moment to gently shift your attention to your breath, by noticing each inhalation and each
exhalation. Observe the changes in your body as you take air in and as you release it. Notice
your belly rising and falling or the change in temperature of the air traveling in and out of
your nose.
Whenever you are ready, begin by identifying someone who you like and who is uncomplicated.
This can be someone who you deeply care about, even a pet, or it can be someone who you know
from a distance but greatly respect. Imagine them sitting in front of you, smiling, and looking
back at you.
Offer them the following statements, focusing on the words as you say them aloud or in
your mind:

I wish you peace . . .

I wish you health . . .

I hope you are without distress, hardship, or misfortune . . .

I wish you love and joy . . .

...

I wish you peace . . .

I wish you health . . .

I hope you are without distress, hardship, or misfortune . . .

I wish you love and joy . . .

(continued )

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Box 7.1 Continued

Notice what emotions and physical sensations emerge as you offer these statements. Warmth?
A smile? It’s also okay to not notice any positive emotions right now.

I wish you peace . . .

I wish you health . . .

I hope you are without distress, hardship, or misfortune . . .

I wish you love and joy . . .

Take a moment now to shift back to your breath, noticing the rise and fall of your belly with each
inhalation and exhalation.
Now bring to mind someone who is a little more difficult. It can be a difficult family member,
work colleague, or political figure. It can even be yourself. It should not be anyone who has abused
you or was the cause of a trauma. Once you have chosen this individual, imagine them sitting in
front of you. Offer them the following statements:

I wish to feel at peace or I wish you peace . . .

I wish for good health or I wish you health . . .

I hope that I am/​you are without distress, hardship, and misfortune . . .

I wish that I/​you experience love and joy . . .

...

I wish to feel at peace or I wish you peace . . .

I wish for good health or I wish you health . . .

I hope that I am/​you are without distress, hardship, and misfortune . . .

I wish that I/​you experience love and joy . . .

Notice any emotions or physical feelings that arise.

I wish to feel at peace or I wish you peace . . .

I wish for good health or I wish you health . . .

I hope that I am/​you are without distress, hardship, and misfortune . . .

I wish that I/​you experience love and joy . . .

Return again to your breath for the next few moments. Take a few deep breaths if you notice
yourself being especially distractible.

(continued )

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Box 7.1 Continued

Now bring to mind an image of the world, offering positive thoughts.

I wish the world peace . . .

I wish the world health . . .

I hope the world is without distress, hardship, or misfortune . . .

I wish the world love and joy . . .

...

I wish the world peace . . .

I wish the world health . . .

I hope the world is without distress, hardship, or misfortune . . .

I wish the world love and joy . . .

Now what emotions and physical symptoms arise?

For the final time, gently shift your attention to your breath . . . and then open your eyes.

Following the practice, ask the client to again rate their mood and then
to reflect on the thoughts, emotions, or physical symptoms they noticed.
If there were positive emotions or thoughts, highlight the connection
between their practice of Loving-​Kindness and those positive emotions.
If there was an improvement in mood, highlight this connection. This
will reinforce learning that the practice leads to more positive mood.

If the client had a negative experience, assess the reasons why. Were
there feelings of discomfort because it felt awkward or disingenuous? If
so, explain that this reaction is expected the first few times they practice
Loving-​Kindness. Did the exercise generate more negative emotions than
positive emotions? If so, validate that this often happens if someone
chooses a person who is too difficult for the initial practice. If there
is sufficient time, have them practice the exercise again with another,
less difficult being (e.g., pet). Was the client’s mind wandering a lot? If
so, validate this experience and explain that one’s mind will typically
wander less with more practice.

It is essential that you reinforce the principles before moving on to

homework. Ask the client what they are taking away from the session or
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the skill. At a minimum, doing so will help you recognize whether the
client has a strong understanding of content and whether some content
needs to be reviewed.

Homework for Practicing Loving-​Kindness

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to
practice the Loving-​Kindness skill daily, recording their mood before
and after on Exercise 7.1. Clients can practice by listening to the
audio, reading the script, or recording and listening to themselves read
the script.

Case Vignettes for Practicing Loving-​Kindness

Case Vignette #1

This vignette demonstrates how the therapist can introduce the skill of
Loving-​Kindness.

T: Today we are starting a new skill called Loving-​Kindness. Have you

heard of this practice before?
C: No, I don’t think so.
T: That’s not surprising. Loving-​Kindness is not a practice that is com-
monly known in Western cultures. It was originally developed from
Buddhist practices as a form of meditation, with Loving-​Kindness
being one of four sublime states of mind. However, Western medicine
has adopted it after recognizing the benefits it has on mental health.
C: So, wait, are we doing something religious here, then?
T: (smiles) No, this practice is non-​religious. It is beneficial whether you
are religious or not. How does that sound?
C: That sounds good.
T: There is a lot of research to show that practicing Loving-​Kindness
leads to improved mood and reduce negative emotions. For example,
one study demonstrated that it led to less anger, pain, and general
distress.

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C: Hmm, cool. Sounds like it could help me.

T: Definitely. This is also a great skill to enhance feelings of connection to
others. I know that is something you have really been struggling with.
C: Yes, I just feel disconnected a lot. It has been better since I started
scheduling social activities into my week, but outside of that, it’s not
a feeling I often have.
T: Well, then, this is a fantastic skill for us to practice.
C: I’m excited.
T: This skill uses imagery.
C: Like Imagining the Positive?
T: It’s a little different. In Loving-​Kindness practice, you will visualize
a living being or the world more generally. Then you will offer that
living being or the world positive thoughts. I will guide you through
the visualization and the positive thoughts to offer. While going
through the practice, be aware of any thoughts, emotions, or physical
sensations that arise. How does all that sound?
C: Interesting.
T: Fantastic. Would you want to try a practice?
C: Yes, sure.

Case Vignette #2

This vignette demonstrates how to handle situations with clients who

struggle to identify an uncomplicated person.

T: Okay, we have just finished our first Loving-​Kindness practice. How

did it go for you?
C: I couldn’t even do it.
T: Can you share more of what you mean by that?
C: I couldn’t do it. You asked me to think of someone who is uncom-
plicated, and I got stuck there. First, I thought of my mom, but
when I did that, I just felt pretty crappy, because I kept thinking
of our argument last week. Then, I thought about my sister, but
we haven’t talked in years. Then, I thought about my dad, and you
know that history. . . . And, then I had trouble thinking about
anyone else.

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T: It seems that you really did get stuck. Many people can get stuck here.
Your struggle to find an uncomplicated person highlights how com-
plicated people can be. Other people can bring up a lot of mixed
emotions, especially people closest to us.
C: I can definitely see that with my family. I’m glad that it’s not just me.
T: It’s definitely not just you. When this happens, a helpful step forward
is to figure out who you will choose before you even start the practice.
We can figure that out together.
C: Okay.
T: Your mom, dad, and sister all feel too complicated right now. Is there
anyone else in your family, like a distant relative, who might feel less
complicated? For example, many people find that grandparents can
be easier to practice this skill with than other family members.
C: My grandparents aren’t living anymore, and I didn’t really know
them when they were alive.
T: Okay. Well, actually, to do this exercise, they do not need to be alive.
Also, you can still choose them even if you didn’t know them, but
sometimes it’s more helpful to start with someone you did know.
C: I don’t know of anyone else in my family.
T: What about someone outside of your family? Are there any friends
who feel less complicated?
C: I don’t feel like I have any friends.
T: I know that’s something we worked on earlier in this treatment. You
scheduled social activities where you met new people and continued to
interact with them. Even if you don’t yet consider them friends, they
may be good candidates for this practice.
C: How would I know if they are good candidates?
T: Great question. Do they bring up any strong negative emotions for
you when you think about them?
C: No.
T: Okay, that already makes them possible good candidates for earlier
practices. Although you can practice Loving-​Kindness with anyone,
including those who bring up many negative feelings, it is easier to
start with someone who brings up little to no negative emotions.
Another requirement is that you can imagine their face or their name.
Can you remember either their face or name?

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C: Yes.
T: Fabulous. It sounds like any of those friends or individuals would be
good candidates. Other possibilities are an old mentor or teacher, an
old friend, a pet, or stranger toward whom you feel compassion or
other positive emotions.
C: I can choose my dog, or I can choose that really nice older woman who
started talking to me while waiting in line at the grocery store.
T: Either of those would be wonderful options. Which of these individuals
would you like to choose for our next practice?
C: Can we start with my dog?
T: Absolutely.

Troubleshooting for Practicing Loving-​Kindness

The most common difficulty is experiencing negative emotions with

the Loving-​Kindness exercises. Clients may report feeling jealousy, anger,
sadness, or irritation. These are normal reactions, especially if the person
they identified for the practice is someone with whom there have been
strained relations. It is important to first normalize the client’s reac-
tion. If there is sufficient time in session, you can lead another prac-
tice, encouraging the client to choose someone less difficult (e.g., a
pet, a houseplant, a teacher/​mentor they once loved) to see if different
emotions arise. Finally, explain to the client that it can often take mul-
tiple practices (even weeks or months) before they experience positive
emotions, which is why we recommend practicing these skills repeatedly
and sometimes for extended time periods.

Another common response is feelings of awkwardness or being dis-

ingenuous. Validate this experience, and explain that over time these
feelings will dissipate.

Another client problem may be that they have no one who is uncom-
plicated in their life; maybe everyone they interact with generates some
negative feelings. If this is the case, see if the client can practice these
exercises with a pet, a houseplant, or a person from their past with
whom they no longer interact.

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Practicing Gratitude

Background

Gratitude is polysemy (i.e., having multiple definitions); it is an emo-

tion, behavior, and thought strategy. Wood and colleagues (2008c,
2010) have suggested the following definitions: recognition and appre-
ciation of the positive, an appreciation of other people, a focus on one’s
possessions, admiration for beauty, a behavioral expression, mindful
awareness of the positive, appreciation that one’s life is time-​limited,
and a healthy comparison to those less fortunate.

From an evolutionary perspective, Gratitude may be a function of

maintaining social connectedness. Indeed, it is believed to be a practice
that explains why humans exhibit reciprocal altruism (Trivers, 1971),
where an organism behaves in a way that undermines its own strength
to enhance the strength of another organism (and the expectation that
this will be reciprocated).

Of all the skills discussed in this chapter, Gratitude has been studied the
most. Research has demonstrated associations between Gratitude and
a number of beneficial mental health outcomes, such as lower levels of
stress and depression (Wood et al., 2008c). Gratitude is also associated
with positive affect (Emmons & McCullough, 2003; McCullough et al.,
2002), including emotions of happiness (McCullough et al., 2002; Van
Overwalle et al., 1995), pride (Van Overwalle et al., 1995), hope (Van
Overwalle et al., 1995), and optimism (Emmons & McCullough, 2003;
McCullough et al., 2002).

In addition, Gratitude has positive interpersonal benefits, including

improved relationships (Algoe & Haidt, 2009), prosocial behavior
(Emmons & McCullough, 2003), greater willingness to forgive (DeShea,
2003), enhanced feelings of connectedness with others (Emmons &
McCullough, 2003; McCullough et al., 2002), and heightened levels
of perceived support (Wood et al., 2008b). More generally, research
has demonstrated the association between Gratitude and positive well-​
being (Emmons & McCullough, 2003; McCullough et al., 2002). As
a treatment skill, Gratitude is defined as: (1) the act of recognizing and

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appreciating something positive in this world, or (2) thinking about

what one appreciates.

The goal of Gratitude as an intervention is to target noticing and

appreciating the positive, as part of attainment of reward, or liking. One
study found that positive appraisals of aid received mediated the re-
lationship between state and trait Gratitude, which may explain why
grateful people tend to feel more Gratitude after receiving aid. However,
some research suggests that anticipation and learning of reward are
implicated in Gratitude (Fox et al., 2015; Wood et al., 2010).

How to Practice Gratitude

After reviewing the science and history of Gratitude, lead your client
through a practice of Gratitude in session. This will help the client better
understand how to complete the homework.

One of the best Gratitude interventions is creating a Gratitude list. There

are many ways to create such lists; however, in this treatment, we have
the client make an ongoing list of unique things they are grateful for
each day. To start, guide the client to use the Exercise 7.2: Gratitude
list, which can be found in the client workbook and also in the ap-
pendix at the end of this therapist guide. Ask the client to record five
unique things (different from the prior day) that they were grateful for
yesterday, ensuring that they rate their mood beforehand and afterward.
Clients may photocopy this exercise from the workbook or down-
load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT).

Clients may struggle here. If you notice this, ask the client to use Finding
the Silver Linings to identify positive aspects of yesterday. If they con-
tinue to struggle, you can remind them that the silver lining need not be
big; it can be small and even silly.

Once the client has identified five unique Gratitude items for yesterday
and written them down on their exercise form, have them rate their mood
again. Then discuss with the client what they noticed when practicing this
skill. Ensure that they understand the rationale of the skill. Ultimately,
the client will generate at least 35 unique items of things they are grateful
for each week. Thinking about things we are grateful for and reviewing

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the cumulative list are great ways to boost mood. Check to see if clients
notice this already in their own mood ratings.

Homework for Practicing Gratitude

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to
record five unique things they are grateful for each day, listing them
on Exercise 7.2: Gratitude. It might be helpful to encourage clients
to identify a time of day to practice and have them set a reminder
on their phone. This increases the likelihood that they will follow
through each day and that it will become routine.

Case Vignettes for Practicing Gratitude

Case Vignette #1

This vignette demonstrates how to handle situations with clients who

struggle to identify Gratitude items.

T: Let’s start with a practice. See if you can write down five things you
are grateful for from yesterday.
C: Okay, but I’m pretty sure there’s nothing. Yesterday was pretty crappy.
T: I’m sorry to hear that yesterday was rough. Would you be willing to
give it a good effort and then we can talk about it?
C: Okay. (thinking, fiddling with his pencil, and then gives up
within a minute) I don’t know. I can’t think of anything. I just keep
on thinking about how shitty my day was. I can’t believe that after
I got locked out of my house, my brother took two hours to get over to
my place to give me the spare key. I just sat out there, bored out of my
mind. And of course, it started raining.
T: I’m sorry that yesterday was so difficult, and I can tell that you are
getting stuck in that right now.
C: Ugh, yes.
T: Let’s see if we can make this easier by starting with a day that was a
decent day. Is there any day this week that you could consider decent?

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C: Today has been okay.

T: That’s great! Let’s go with today. What is at least one thing you can
think of to be grateful for today?
C: (thinking for a few seconds and then gives up) I really don’t know.
T: I noticed that you thought about it for less than a minute. Let’s try to
give it some more time to think of at least one thing you are grateful for.
C: Okay. (thinking for a couple of minutes) I guess I’m grateful for not
being locked out of my house today.
T: That’s great! Let’s go with that. Can you write that down as one thing
to be grateful for today?
C: Oh, okay. (client writes)
T: What else?
C: I really don’t know.
T: Sometimes when we get stuck, it can be helpful to try silver linings.
C: So what’s my situation?
T: The situation can be today. Or, if you want to get more specific, it can
be sitting in therapy today.
C: Okay, I’ll go with sitting in therapy today as the situation.
T: Fantastic.
C: Well, one silver lining of sitting in therapy today is that I get to speak
with you, which usually makes me feel better. Another is that I am
learning something new. I guess one more is that I managed to get
here on time so that I could get the full session.
T: These are all great! You now have four gratitude items for today so far.
C: Oh, I see. Okay, my silver linings are also things to be grateful for.
T: Precisely.
C: Okay, but I really can’t think of anything else.
T: Another helpful tool when getting stuck is to think of things you have that
others might not. These can be really basic, like having a home to live in.
It might be having money for food, being able to see, hear, and speak,
being able to walk and use your arms . . .
C: Okay, I get the point. So there are actually a lot more than five things
I can write down for today.
T: There are, and what we are doing today and over the next week is
training your brain to start noticing things to be grateful for in order
to elicit that feeling of gratitude, which has a lot of beneficial effects
on our well-​being.
C: Makes sense. I think I get it now.
T: Fantastic.

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Case Vignette #2

This vignette demonstrates how to respond to clients who struggled

with this assignment for homework.

C: I kind of did my homework this week. I tried.

T: Well, that’s great. Let’s see what you’ve got.
C: I tried doing two gratitude exercises, and then I gave up.
T: Hmm, okay, we will definitely talk through it to figure out what
happened. Either way, can I take a look at your exercise sheets?
C: Here you go.
T: I can see here that on Friday you wrote down three things you were
grateful for, and then only two things the next day, and nothing after
that. Is that right?
C: Yeah, I’m sorry.
T: That’s okay. What do you think might have happened?
C: I had a really hard time coming up with as many as five things I was
grateful for on Friday. Then, on Saturday, it was even harder for me
to think of things to be grateful for that were different from Friday.
So I just gave up after that.
T: It sounds like you gave it a good effort. However, the assignment
might have been a little too difficult to start with.
C: Maybe.
T: Okay, let’s adjust the assignment so that it’s more manageable, and
then over time you can work back up to five gratitude items per day.
C: Is five a special number?
T: (smiles) No, in fact you never have to work your way up to five items
per day. It’s an arbitrary number that is intended to train your mind
to notice the positive more. That said, since you managed to identify
two or three items on Friday and Saturday, let’s see if we can start
with two unique gratitude items per day.
C: I think I can do that. Basically, I have to come up with two things per
day that I am grateful for that are different from the prior day.
T: Exactly. In fact, let’s practice in session, by writing out two gratitude
items for as many days of last week as you can remember. We can start
with yesterday. What are two things you might have been grateful for
yesterday?
C: Okay, um, I was really grateful that my husband cooked dinner for
me. It really helped reduce some of my stress.

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T: Fabulous. Let’s write that down. What else?

C: I was also really grateful that I had time to go for a long walk that
morning.
T: Great. Now what about Wednesday? What were two things you were
grateful for that day?
C: That’s when my boss gave me the positive feedback on my report.
I was really appreciative that he took the time to do that. Also, I was
grateful that I didn’t have to redo the report.
T: Fantastic. Let’s see if we can try the day before that too.
C: On Tuesday? That was a while ago. Hmm, I’m really not sure. I can’t
remember Tuesday all that well. I went to work that day and didn’t
do much in the evening. I really can’t remember anything significant.
I guess I can be grateful that nothing eventful happened.
T: Absolutely. And we can stop there. Do you feel more comfortable with
the homework now?
C: Yes, definitely.
T: Would you be willing to try that this week?

Case Vignette #3

This vignette demonstrates how to practice this skill with clients who
have considerable hardships and believe that they have nothing to be
grateful for.

T: Let’s try a practice of Gratitude. On your exercise sheet, see if you can
write down five things you are grateful for in the last day. But before
you do that, go ahead and rate your mood on a 0-​to-​10 scale.
C: Okay. I guess I’m at a 4 out of 10 right now . . . (writing) . . . As for
five things I’m grateful for, I have no idea. . . . Um, I don’t know. In
fact, maybe I’m at 2 out of 10 for my mood.
T: It sounds like your mood just decreased when thinking about the
practice.
C: It did
T: What’s coming up for you?
C: I really don’t think I have things to be grateful for right now. I’m un-
employed. I can barely pay the bills. I basically have no friends. My

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sister won’t talk to me. I’m never good enough for my mother. And, my
father never cared about me.
T: That’s a lot. I can imagine that when you think of all that, your mood
understandably decreases.
C: Yeah.
T: You’ve had some definite hardships in your life, especially more re-
cently. That’s undeniable, and it’s important to acknowledge that. At
the same time, getting stuck or dwelling on those hardships is prob-
lematic. Do you feel like you might be dwelling on these negative
experiences?
C: I guess so.
T: That’s something that happens often, isn’t it?
C: Yes, it happens like all the time.
T: I thought so. In fact, that’s one of the primary reasons you came to this
treatment. You were dwelling on the past and experiencing a lot of
depression.
C: All of that’s true.
T: So in this treatment, we are going to try something different. Would
you be willing to try something new?
C: Okay.
T: We are going to practice stretching your brain to start noticing things
that you can be grateful for each day. Science has shown again and
again how helpful doing this is for our mood.
C: That sounds like silver linings.
T: It is very similar to silver linings. In fact, we can use silver linings to
help identify Gratitude items.
C: Okay.
T: Like silver linings, Gratitude items can be big, small, or even silly.
What is one small thing that you might be grateful for today?
C: I still really don’t know.
T: That’s okay. One really helpful way to identify gratitude items is to
think of things you have that others might not have or that you previ-
ously did not have.
C: Like what? I feel like others have plenty of things that I don’t.
T: Some definitely do. Think basic needs. What are some basic human
needs?
C: Air, food, shelter, and water.

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T: Great. Those are actually four things you can identify being grateful
for today. You have clean air to breathe and clean water to drink. You
can also feed yourself and have a place to live.
C: I guess all of that is true.
T: Also, sometimes we take for granted basic functioning. For example,
we forget that not everyone has all four limbs or the ability to see or
hear. These are also things to be grateful for.
C: I see.
T: Sometimes it’s best to start with these items, and as you practice this
skill more, you might start noticing other things to be grateful for
every day. For example, you might start noticing that there was more
wildlife on your walk, which you were grateful for. Or maybe you
forgot to look up something on your computer before you left the
house, and you are grateful that you could look up the answer on your
phone without going back home.
C: Okay, I get it. One thing I can be grateful for today is that I have
therapy to go to.
T: (smiles) Precisely.

Troubleshooting for Practicing Gratitude

With the skill of Gratitude, a common difficulty will be clients who suggest
that they have nothing for which to be grateful. Many clients feel depressed
because of their considerable hardships. It is important to be validating of
this and practice small downward comparisons with them. Adding basic
needs and functioning to the Gratitude list can help clients realize that
there are always some things for which to be grateful. These might include
still being alive, ability to see and hear, ability to walk or use one’s arms,
ability to attend therapy and receive medical care, having shelter over one’s
head, ability to pay for food, and having some support in their lives. There
are many examples of this. Encourage clients to be creative. Also, returning
to the skill of Finding the Silver Linings can be helpful for this.

Another common difficulty is struggling to identify as many as five

things clients are grateful for each day. The number of Gratitude items
per day can be adjusted to the client. If the client is really struggling
to identify five items per day, they can start with one or two items and
build up from there.

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Practicing Generosity

Background

Generosity is the act of giving by choice without expecting something

in return. It is not limited to material goods, even though it is typically
perceived this way; Generosity can be giving of one’s time, energy, know-
ledge, or other resources.

Humans have engaged in generous and altruistic behavior since possibly

the origin of humankind. Indeed, sociological studies have found that
Generosity is cross-​cultural and occurs across age groups (Aknin et al.,
2015). However, our understanding of why humans across cultures and
history engage in generous acts is limited to theories. Some theories state
that generous behavior improves partner selection (Hamilton, 1963),
enhances one’s reputation (Bénabou & Tirole, 2006), and increases the
likelihood of receiving help (Trivers, 1971).

There is important evidence to support the theory that humans evolved

with generous behavior to ensure they receive help when needed. Current
research has demonstrated that spending money on others predicts
increased happiness (Dunn et al., 2008), and acts of kindness are re-
ported more by happier people (Otake et al., 2006). Further, generosity
has been found to be socially contagious (Tsvetkova & Macy, 2014), in
that one is more likely to be generous when experiencing a generous act.

It has been suggested that activities like Generosity protect against risk
for negative outcomes (Layous et al., 2014). In one study, daily pro-
social behavior moderated the effects of stress on affect (Raposa et al.,
2016). Indeed, research more generally has demonstrated a link be-
tween Generosity and positive outcomes, especially when Generosity
is in the form of volunteering. Those positive outcomes include posi-
tive affect (Aknin et al., 2015; Otake et al., 2006), greater well-​being
(Borgonovi, 2008; Thoits & Hewitt, 2001), lower mortality rates
(Musick et al., 1999; Oman et al., 1999), and decreased depression
(Musick & Wilson, 2003).

In PAT, Generosity is used to target the attainment of reward, or liking,

and learning of reward. Research into the mechanisms of Generosity has
found that tweaking oxytocin levels (Zak et al., 2007), disrupting dorso-
lateral and dorsomedial prefrontal cortical functioning (Christov-​Moore

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et al., 2017), and MDMA administration (Kirkpatrick et al., 2015) re-

sult in enhanced Generosity.

How to Practice Generosity

It will be largely impractical for clients to practice an actual act of

Generosity in session—​although there may be exceptions that can be
done in session, such as the client texting a friend and offering to help
with something. Therefore, dedicate most of the session practice to
generating a thorough list of Generosity activities clients can do over the
following week.

Remind clients that Generosity need not be material, even though this
is often how we think of it. Generosity can be free of monetary cost and
unconstrained by time and energy when we think of it in creative ways.
For example, it can take the form of time, energy, knowledge, and other
resources. It also is worth discussing with the client that Generosity need
not be toward another person; we can also be generous toward ourselves,
animals, and the world.

Have the client generate a list of generous acts that they could do, using
Exercise 7.3: Generosity, which can be found in the client workbook
and also in the appendix at the end of this therapist guide. Ensure that
these activities include both material and non-​material activities. Ten to
20 items are a good amount, and encourage clients to continue adding
to this list. Instruct clients to rate their mood before and after each act
of Generosity, and ask them to notice how their mood state changes as a
result of engaging in Generosity in order to deepen reward learning (i.e.,
their actions produced more positive mood).

Homework for Practicing Generosity

Clients may photocopy exercises from the workbook or down-

load multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT). For homework, ask your clients to
practice three acts of Generosity this week to be recorded on the
Exercise 7.3: Generosity sheets, along with the day(s) they plan to
complete them. Scheduling these activities in advance will increase

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the likelihood that they are completed. One exercise form/​sheet will
be used for each act of generosity.

Case Vignettes for Practicing Generosity

Case Vignette #1

This vignette demonstrates how to respond to a client who fears they do

not have enough time or resources to be generous.

C: I understand that being generous is really important. I wish I was

more generous. But I feel like I can’t be more generous. Does that
make me a bad person?
T: Absolutely not. Let’s talk through what you mean by “can’t be more
generous.”
C: Well, I feel like I can’t. I want to be. I really do, but I’m so tired, and
money is tight, and I don’t know . . .
T: I’m hearing that you feel like you have nothing left to give.
C: Yes, that’s exactly right! I wish I could give my time, but I already feel
busy. I wish I could give money, but I also know it’s important for me
to save for my retirement. I also would love to give coworkers more
effort, but I already feel so drained.
T: That all makes sense. A lot of people feel this way. They fear giving,
because they believe that they don’t have enough to give.
C: Yes. That’s me.
T: When we think of Generosity in the traditional sense, not having
enough can be a reality. We may not have money to give. Or we may
not have the time to help someone move into a new home. Or we may
be too drained to call a friend and listen to their day.
C: So it’s not just me.
T: Definitely not. We all have our limitations.
C: I’m glad to hear this, but I am also disappointed that I am not able
to be more generous, especially if it’s supposed to help me too.
T: The great news is that anyone can be more generous if we look at
Generosity differently. Traditionally, people think of Generosity as
money, physical help, or time and energy.
C: That’s the way I think of it.
T: That’s not surprising. In the traditional sense, Generosity is limited.
However, Generosity can be viewed as limitless if you consider it in

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limitless ways. In addition to time, physical help, objects, and money,

Generosity can be in the form of knowledge, advice, feedback, com-
fort, validation, a smile, love, care, compassion, and empathy.
C: I guess I never thought of those other ways to be generous.
T: Generosity can be toward other people, but it can also be toward
one’s self, animals, or the world more generally. Anyone and anything
can be the recipient of Generosity. In these ways, Generosity can be
limitless.
C: I can see that.
T: Can you think of one example of a way that you can be generous this
week despite being so busy and tired?
C: I can hug my daughter or smile at a colleague.
T: Great ideas.
C: I guess I can also try to garden more, which I love, because that would
be giving something back to the world.
T: Absolutely.
C: Would making eco-​friendly choices, like buying more eco-​friendly
products instead of alternatives, be another example?
T: For sure. Generosity can take countless forms and can look different
for each individual who engages in the practice.
C: Okay, I get it now.

Case Vignette #2

This vignette demonstrates how to respond to clients who avoid being

generous because they fear their Generosity will not be appreciated.

C: I didn’t do my homework again. It was just too hard.

T: Well, let’s definitely talk about that. I’m assuming you’re referring to
the Generosity assignment?
C: Yes, the one where I was supposed to cook for my mom and bring
her food.
T: I remember. What do you think made the activity so difficult?
C: I don’t know. It just was.
T: Was there not enough time to cook? Or did cooking for someone else
feel overwhelming?
C: No, neither. I actually cooked the meal, and I was about to head out
the door to surprise my mom with it.
T: What happened then?

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C: I remembered the last time I did something nice for her.

T: What happened the last time you did something nice for her?
C: She didn’t seem to care. I figured this time would be the same.
T: You were afraid that your Generosity wouldn’t be appreciated.
C: Yeah, exactly. A few months ago, I tried to clean up my mom’s garage,
and she didn’t even say “thank you.” I don’t even know if she noticed.
T: That sounds like it was very frustrating and hurtful.
C: It was! I put so much effort into it. I would have liked some recognition.
T: You are not alone in feeling hurt by generous deeds not being noticed
or appreciated. Generosity requires us to give some of our resources,
making us vulnerable.
C: I hate feeling vulnerable.
T: Most people do. People don’t like to feel exposed and open to hurt.
C: Right.
T: At the same time, sometimes we have to feel vulnerability to achieve
our goals. For example, you felt some vulnerability scheduling those
social activities earlier in treatment, and yet by doing so, you devel-
oped more friendships.
C: I did.
T: In the same way, feeling vulnerable and hurt might be a side ef-
fect of doing a generous deed sometimes. However, the payout is the
possibility of increasing your mood overall and feeling more positive
emotions, like pride, love, compassion, and appreciative joy, which is
something we will learn next week.
C: I’m not sure it’s worth it.
T: I remember you saying the same thing about social activities. (smiles)
Did you find doing those social activities worth it?
C: They were. I can give this a shot. But does that mean I have to feel bad
every time I am generous?
T: Just shifting your view of what Generosity is can lessen some of the
hurt if the deed is not appreciated.
C: How?
T: Remember, we defined Generosity as “giving without expecting in re-
turn.” When we do that, the generous deed is not about the outcome
but rather about the activity itself. It’s doing something not to achieve
a goal but to do it because it is important. An example of this is your
daily walks. From what I heard you say, you don’t go on your daily
walks to lose weight, you walk every day because it’s important to you.
C: That’s right. Okay, I think I get it.

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Troubleshooting for Practicing Generosity

For Generosity, the most common concern among clients is not having
the time or resources to perform generous acts. Validate this and explain
that Generosity need not take much—​or any—​of one’s resources. An act of
Generosity can be smiling at someone, thinking a positive thought, offering
a piece of advice, actively listening, or letting someone borrow something.
It can be toward another person, a pet, or toward the world. It can also be
an act of self-​care. Ensure that clients understand that sometimes we find
ourselves doing too much for others and not enough for ourselves. When
this happens, acts of generosity should be dedicated to oneself.

Another common concern about Generosity is that something would

not be appreciated if given. This is a very likely outcome of Generosity
that you should acknowledge. At the same time, it is important to re-
mind clients that we cannot control other people’s behavior. Also, ex-
plain that research shows that the act of giving, regardless of whether
it is appreciated, has benefits. If clients are still struggling with not re-
ceiving appreciation, highlight their choice of giving something with
openness versus an expectation of appreciation. The latter is likely to
lead to feelings of regret and resentment.

Practicing Appreciative Joy

Background

Appreciative Joy is the experience of positive emotions that emerge from

the success of others (Grossman, 2015; Zeng et al., 2017). It is also
a practice that is intended to generate these types of emotions. Like
Loving-​Kindness, Appreciative Joy stems from Eastern spiritual practices
and is identified as one of four states of wholesomeness in the Buddhist
tradition (Grossman, 2015).

During the practice, one offers positive thoughts of continued good for-
tune to another, while being aware of emotions, thoughts, and physical
symptoms that arise. Unlike Loving-​Kindness, clients begin by thinking
of someone who recently had fortune or success come to them and of-
fering them additional or continued fortune.

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There is evidence to suggest that Appreciative Joy has a beneficial effect on

mental health outcomes. For example, more experiences of appreciative
joy have been associated with more positive emotions, life satisfaction,
and trait happiness (Zeng et al., 2017). More generally, Appreciative Joy
enhances feelings of connectedness.

In PAT, Appreciative Joy is designed to target the attainment of reward,

or liking.

How to Practice Appreciative Joy

As with Loving-​Kindness, the client practices an Appreciative Joy exercise

with you in session. You will lead the client through this exercise in ses-
sion to allow for processing and troubleshooting, by reading the guided
instructions script in Box 7.2. Ensure that the client records their mood
beforehand using the Exercise 7.4: Appreciative Joy form, which can be
found in the client workbook and also in the appendix at the end of this
therapist guide. Note that a recording of the script is available for both
you and your clients on the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT), and clients may photocopy this exercise
from the workbook or download multiple copies from the website.

Box 7.2 Guided Instructions for Practicing Appreciative Joy

Find a comfortable position someplace with little to no distractions. It can be helpful to sit in a
chair with your feet flat on the ground, your back upright, and your eyes closed or gently resting
on a spot in front of you.
If you notice that your mind is racing, wandering, or being especially distractible today, take
a moment to gently shift your attention to your breath, by noticing each inhalation and each
exhalation. Observe the changes in your body as you take air in and as you release it. Notice your
belly rising and falling or the change in temperature of the air traveling in and out of your nose.
Whenever you are ready, begin by identifying someone who you like and who is uncomplicated.
This can be someone who you deeply care about, even a pet, or it can be someone who you know
from a distance but greatly respect. Imagine them sitting in front of you, smiling, and looking
back at you.
Identify one good fortune that they have. Notice the emotions that arise as you identify what
that is.

(continued )

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Box 7.2 Continued

Offer them the following statements, focusing on the words as you say them aloud or in
your mind:

I am happy you are happy and content . . .

I hope your success stays with you . . .

I hope your wealth continues to grow . . .

...

I am happy you are happy and content . . .

I hope your success stays with you . . .

I hope your wealth continues to grow . . .

Notice what emotions and physical sensations emerge as you offer these statements. Joy? A smile?
It’s also okay to not have any positive emotions right now.
Take a moment to shift back to your breath, noticing the rise and fall of your belly with each
inhalation and exhalation.
Now bring to mind someone who is a little more difficult. It can be yourself, a friend, or a family
member. Once you have chosen this individual, imagine them sitting in front of you.
Identify one good fortune that they have. Notice the emotions that arise as you identify what that
is. Offer them the following statements:

I am happy you are happy and content . . .

I hope your success stays with you . . .

I hope your wealth continues to grow . . .

...

I am happy you are happy and content . . .

I hope your success stays with you . . .

I hope your wealth continues to grow . . .

Notice any emotions or physical feelings that arise.

For the final time, gently shift your attention to your breath . . . and then open your eyes.

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Following the practice, the client again rates their mood. Then process
their experience by asking about the thoughts, emotions, or physical
symptoms they noticed. If the client experienced positive emotions
or thoughts, highlight the connection between their practice of
Appreciative Joy and those positive emotions. If there was an improve-
ment in mood, highlight this connection. This will reinforce learning
that the practice leads to more positive mood.

If the client had a negative experience, assess the reasons why. Were there
feelings of discomfort because it felt awkward or disingenuous? If so, ex-
plain that this is expected the first few times they practice Appreciative Joy.
Did this exercise generate more negative emotions than positive emotions?
If so, validate that this often happens if someone chooses a person who is
too difficult for the initial practice. If there is sufficient time, have them
practice the exercise again with another, less difficult being (e.g., pet). Was
their mind wandering a lot? If so, validate this experience and explain that
one’s mind will typically wander less with more practice.

Homework for Practicing Appreciative Joy

Clients may photocopy exercises from the workbook or download multiple

copies at the Treatments That WorkTM website (www.oxfordclinicalpsych.
com/PAT). For homework, ask your clients to practice the Appreciative Joy
exercise daily, recording their mood before and after on Exercise 7.4. Clients
can practice by listening to the audio, reading the script, or recording and
listening to themselves reading the script.

Case Vignettes for Practicing Appreciative Joy

Case Vignette #1

The following vignette demonstrates how you can introduce Appreciative Joy.

T: The final skill is Appreciative Joy. Is Appreciative Joy something you’ve

heard of before?
C: No, I’ve never heard of Appreciative—​what was it?

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T: (smiles) Appreciative Joy. Appreciative Joy is both a practice and an

emotion. It is the feeling of joy or other positive emotions as a result
of the joy that someone else experiences. It is also a skill we practice to
cultivate that emotion.
C: Cultivate? What does that mean?
T: Cultivate means to foster or promote growth of. Basically, this is a skill
you will practice that will hopefully bring on more positive feelings
over time.
C: Oh, I see. So this is a joy that we feel from someone else’s joy.
T: Exactly. Have you ever experienced that before—​feeling joy or positive
emotions as a result of seeing someone else experience a positive emotion?
C: It would happen all of the time with my daughter when she was a
little girl. She would get so happy opening presents, riding her bike,
or snuggling up next to our golden retriever that I couldn’t help but
smile, knowing that she was so happy.
T: I am noticing that you are even smiling right now as you talk about it.
C: Oh! I guess I am! So, yes, I’ve definitely experienced Appreciative Joy.
I just didn’t know there was a name for it.
T: Most people are not familiar with the name. Like Loving-​Kindness, it
was originally developed as a form of meditation in Buddhist practice.
And, also like Loving-​Kindness, there is research showing that practicing
Appreciative Joy leads to more positive emotions, especially connectedness.
C: I can see that. Well, I really liked Loving-​Kindness, so I think I’ll like
this too.
T: Great. The practice is very similar. Would you be willing to try a prac-
tice right now?
C: That sounds great.

Case Vignette #2

This vignette demonstrates how to handle situations with clients who

only feel negative emotions during a practice of Appreciative Joy.

T: Now that we’ve completed your first practice of Appreciative Joy, what
did you notice?
C: Ugh, that did not go well.
T: Can you tell me more?
C: I just feel bad after doing it.

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T: Okay, it sounds like the practice brought up some negative emotions.

Can you identify or label at least one specific negative emotion you
experienced during the practice?
C: Definitely jealousy . . . and shame.
T: Those are certainly difficult negative emotions.
C: They are.
T: Well, it might be helpful to better understand what led to those neg-
ative emotions in the practice. What person did you identify for the
practice?
C: My best friend from childhood.
T: Okay, and were you able to bring an image of his face to mind?
C: I did—​pretty vividly, too. But as soon as I started offering him those
statements, I started imagining all of his fortune, and that got me
thinking about everything I don’t have. Like, he has a wife, kids, a
huge house, and a great job. I’m unemployed and can barely pay my
studio apartment rent. I am such a failure.
T: It sounds like you went down a downward spiral during this exercise.
C: Definitely.
T: It is not uncommon for this practice to bring up some negative emotions.
In fact, part of this practice is noticing and acknowledging any
emotions—​positive or negative—​that emerge. The intention is not to
change them, but rather to just observe them, as difficult as this might be.
C: I remember—​it was the same with Loving-​Kindness. It’s only after
lots of practice that we might notice feeling better.
T: Exactly.
C: But I liked Loving-​Kindness a lot better. It typically made me feel
calm. This one didn’t.
T: I’m wondering if part of the reason you reacted so strongly to this
exercise is that you were assuming joy or fortune is limited. Do you
remember our discussion of Generosity?
C: That if I think of Generosity as limited, it can be hard to be generous.
However, if I think of it as unlimited, it is easier to find ways to give.
T: Precisely. That was a really nice summary. Appreciative Joy is the
same. It can be easier to generate positive feelings toward another for
their joy and fortune if we recognize that someone else’s fortune does
not affect our own.
C: Like maybe one day we both can own our own homes and have a
family? And one day, I will hopefully get a job too.

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T: Exactly. Also, when feelings of jealousy emerge from an Appreciative

Joy practice, Gratitude can be a helpful skill to practice.
C: That makes sense. And I do have a good amount to be grateful for.
T: Let’s try one more thing. Instead of choosing your friend, who might
be too complicated for your first practice, let’s choose someone less com-
plicated for your next practice. Is there someone or some pet you can’t
help but feel joy when they are happy?
C: My dog. She is so funny when she gets excited. She starts running and
jumping around and licking my face. I love seeing her happy.
T: Wonderful. Let’s do this practice with her next.

Troubleshooting for Practicing Appreciative Joy

The most common client difficulty in learning the skill of Appreciative

Joy is experiencing negative emotions with the exercises. Clients may
report feeling jealousy, anger, sadness, or irritation. These are normal
reactions, especially if the person they identified for the exercise is
someone who is “difficult” for a variety of reasons. It is important to first
normalize the client’s reaction. If there is sufficient time in session, you
can lead another practice, encouraging the client to choose someone less
difficult (e.g., a pet, a teacher/​mentor they once loved) to see if different
emotions arise. Finally, explain to the client that it can often take mul-
tiple practices (even weeks or months) before they experience positive
emotions, which is why we recommend practicing these skills repeatedly
and sometimes for extended time periods.

Other common responses to Appreciative Joy exercises (similar to Loving-​

Kindness) are feelings of awkwardness or being disingenuous. Validate
this experience, and explain that over time these feelings will dissipate.
Also, clients can choose to modify the statements that are offered during
the practice of Appreciative Joy to better reflect what they are able to
think or feel (e.g., “I am glad that you are doing well”).

Clients sometimes report that they have no one who is uncomplicated

in their lives; maybe everyone with whom they interact generates some
negative feelings. If this is case, see if they can practice these exercises
with a pet, a houseplant, or a person from their past who they may no
longer interact with.

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MODULE 3

Treatment Gains
and Relapse
Prevention
14
145

CHAPTER 8
Continuing the Journey
After Treatment

(Corresponds to c­ hapter 8 of client workbook)

Materials Needed 145

Goals 146
Summary of Information in Chapter 8 of Client
Workbook 146
Key Concepts 146
Reviewing Treatment Accomplishments 147
Continued Practice 148
Dealing with Challenging Times and Barriers 149
Case Vignette 150
Troubleshooting 150

Materials Needed

■ Exercise 8.1: My Progress Assessment (all exercises are included in

the client workbook and also included in the appendix at the end of
this therapist guide)
■ Exercise 8.2: My Long-​Term Goals
■ Exercise 8.3: Maintaining My Gains
■ Exercise 8.4: Overcoming Barriers
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Goals

■ Review content from last session and answer any questions.

■ Identify and review treatment gains.
■ Review long-​term goals.
■ Discuss and troubleshoot continued practice barriers.
■ Discuss how to manage “high-​risk” times (lapse vs. relapse).

Summary of Information in Chapter 8 of Client Workbook

■ Evidence suggests that continued practice is an essential aspect of

maintaining therapy gains.
■ Identifying long-​term goals promotes continued practice after treat-
ment has ended.
■ Making plans for overcoming barriers help clients anticipate and
cope with circumstances that prevent ongoing skill training.
■ A lapse is a temporary return of symptoms, whereas a relapse is a re-
turn to the pretreatment baseline. High-​risk times or triggers can fa-
cilitate lapse/​relapse. Awareness and a management plan can reduce
the likelihood of lapse/​relapse.

Key Concepts

The key concept of this chapter is to prepare clients for treatment ter-
mination. The final session is dedicated to reviewing the client’s prog-
ress, identifying long-​term treatment goals, and identifying strategies to
maintain gains and cope with difficult times. You will reinforce the idea
of continued practice to maintain and refine treatment gains. Assessing
barriers can help clients cope with difficult times. Educate your clients
on the difference between lapse and relapse and reinforce the benefits of
continued practice and awareness of stressful triggers to maintain a pos-
itive mood cycle and upward spirals. Goals for the client are to:

■ Begin the process of independent practice.

■ Review and identify treatment gains and long-​term goals.
■ Build a plan on how to troubleshoot difficult times and barriers.
■ Understand and appreciate the difference between lapse and relapse.

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Reviewing Treatment Accomplishments

Clients respond differently to the end of treatment: Some look for-

ward to the last session, while others experience discomfort or even fear.
Assure the client that this is natural. As with most skills, we learn with
the support of someone else, it can be scary to continue without that
person’s help and presence in our lives. Be aware of negative thoughts
common in individuals with emotional disorders such as, “I cannot do
this on my own,” “I will relapse without my therapist’s help,” or “there
are skills I have not mastered yet.” Activities in this chapter are designed
to combat those thoughts by assisting the client to develop a sense of
ownership and mastery. It is essential to start reminding clients that
treatment is coming to an end at least two weeks before the last session.
As discussed in this chapter, ending treatment marks the beginning of
continued practice. It is by no means an end to learning and continuous
improvement.

Begin the last session by complimenting your client for completing the
Positive Affect Treatment (PAT). Take a moment and help your client
pause, notice, and appreciate the steps they have taken and the efforts
they have made over the last several months. Remind them to take own-
ership of their work and give themselves praise for it. Ask them about
their positive feelings as they do so. Do they feel pride, excitement, and
a sense of ownership? Have them savor their accomplishments!

Next, review client progress to determine the skills they have mastered
and the ones that require further work. As you review the questions in
Exercise 8.1: My Progress Assessment, remind clients that progress is
rarely linear.

Progress is assessed most accurately by examining the objective change

in the weekly scores on the standardized questionnaires rather than
asking clients how they feel. Explain how fluctuations in the scores can
be confusing and feel uncomfortable but are common and expected.
Discuss how the data serves as one source of information about the
client’s progress rather than being an indicator of who they are. Remind
your client that treatment does not take place in a vacuum: Changes in
life circumstances, health, and society are expected to influence one’s
mood. Treatment gains—​increases in positive mood and decreases in

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negative mood—​will help temper the impact of internal and external

influences.

Encourage clients to take ownership of their effort and the energy they
put into this treatment. Remind clients to think of progress as an on-
going process that continues after treatment. Strategies to maintain
and further improve the application of the skills they have learned are
reviewed next.

At this point, administer the questions in Exercise 8.1 to the client. The
exercise can be found in the client workbook and also in the appendix at
the end of this therapist guide. You and your clients may photocopy this
exercise from the workbook or download multiple copies from the website.

If your client endorses significant improvements to items 1 or 2 on Exercise

8.1: My Progress Assessment, congratulate them for their hard work and
their success. Then go to the section just below on “Continued Practice.”

If your client does not endorse improvement to items 1 or 2, review

their answers to items 4 through 12 to identify which specific skill sets
may be revisited to achieve further gains.

Continued Practice

An effective way to promote continued practice after treatment is to

create a long-​term goal list, as shown in Exercise 8.2: My Long-​Term
Goals. It can be found in the client workbook and also in the appendix
at the end of this therapist guide. Encourage the client to think about
the following questions:

■ What was this treatment in service of?

■ Why did you want to improve your mood?

Writing down the concrete steps creates a sense of structure and ac-
countability. The goal list should include at least one of the skills learned.
Examples are “Being a more present parent,” “Continue to nurture the
relationship with a friend,” and “Stay physically active.”

Next, use Exercise 8.3: Maintaining My Gains to generate steps to

maintain treatment gains through concrete practices in each of the three

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skills areas: positive activities with savoring the moment, thinking pos-
itively, and building positivity. For example, positive activities designed
to continue nurturing a friendship may include calling a friend once a
week. This exercise can be found in the client workbook and also in the
appendix at the end of this therapist guide.

Dealing with Challenging Times and Barriers

Research has shown that continued practice after treatment reduces

a client’s risk of relapse. The concept of continued practice is best
explained by asking a client about skills they have learned in life, such
as learning how to walk, bicycle, or drive; learning a new language or
sport; or learning how to use a smartphone or computer. Ask your client
to imagine what would happen if they stopped practicing after they
learned how to drive or use a computer. While the theoretical know-
ledge can more easily be retained, the practical knowledge decreases over
time. Thus, the most crucial time for skill maintenance is early on. Once
a skill has been used repeatedly, such as driving, it will become second
nature.

Help clients to complete Exercise 8.4: Overcoming Barriers, which can

be found in the client workbook and also in the appendix at the end of
this therapist guide, to identify the factors that may impede or interrupt
effective practice of all of the skills they have learned. Ask the following
questions:

■ What do you anticipate getting in the way of you practicing your skills as
you move forward?
■ What do you expect to trip you up?
■ Which are the more difficult skills for you?
■ What stressful experiences make it more difficult for you to practice cer-
tain skills?

The combination of anticipating and dealing with future barriers is a pow-

erful tool moving forward. Ask your client to list three barriers on the
exercise sheet, and discuss one to three steps they can take to avoid each
barrier. Examples include scheduling regular time in their day to practice,
setting reminders on their phone, reviewing their workbook once a week
or month, and continuing to practice the more difficult skills.

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Case Vignette

This vignette demonstrates how the therapist handles a client’s fear

about therapy ending.

C: I understand that I made some progress, but I feel I am not ready to

continue on my own.
T: You have certainly shown progress. Can you tell me why you think
you are not ready to continue on your own?
C: I am worried I will forget how to use the skills I learned.
T: I understand your concern. Remember the analogy with learning
how to drive?
C: Yes, you used it a lot. (smile)
T: Yes, indeed! So when you passed your driving test and your instructor
sent you off by yourself, did you forget all the skills you had learned?
C: Of course not.
T: So, what happened instead?
C: Well, I just kept driving, and it became easier over time. I started
feeling more confident that I knew how to drive a car and what to do
in difficult situations.
T: So, how does this apply to ending treatment?
C: Well, I guess if I continue to apply the skills I learned, the better and
more confident I will become.
T: Remember that all the skills you learned are described in detail in
your workbook. I would encourage you to review them once in a
while. You can also review your exercise sheets.
C: Do you recommend I continue to fill out the exercise sheets daily?
T: This can be a helpful practice for some clients. It depends on what
works best for you. You can formally or informally continue the
exercises. I would encourage you to test out what works best with your
daily practices.

Troubleshooting

Clients sometimes express concern that they have not improved as much
as they had hoped. Some may acknowledge that they have improved but
minimize their improvement. As outlined earlier, using objective data
from standardized questionnaires (e.g., Positive and Negative Affect

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Schedule and Depression, Anxiety and Stress Scales) is an effective way

to evaluate their improvement. Emphasize the importance of change
relative to baseline severity levels. Discounting progress is common in
clients with anhedonia. An exercise in “Attending to the Positive” can be
a powerful opportunity to practice its application: that is, the client can
generate silver linings of the treatment (Finding the Silver Linings), how
these silver linings contributed to what they learned (Taking Ownership),
and how the client can imagine moving forward positively (Imagining
the Positive). Re-​emphasize the concept of continued practice, and that
the end of treatment is the beginning of the client’s self-​guided journey.
The analogy of owning a toolbox filled with powerful tools at their dis-
posal is a helpful way to increase confidence, ownership, and positivity.

Some clients are afraid to relapse either because they have suffered mul-
tiple prior treatment failures or they mistrust their treatment gains.
Whatever the reason for their concern, it is important for you to prop-
erly educate clients about the difference between a lapse and a relapse
and when to seek additional help.

Start by reminding clients that forming new habits is challenging, es-

pecially when the old habits have become automatic. Explain that it
is normal to experience moments where they fall back into old habits.
Prime times are stressful times. Again, remind clients about other new
behaviors they have developed, such as eating healthy or exercising, and
how hard it is to keep doing them when buried in deadlines or after
recovering from a cold. Explain that those moments are called lapses
or slips. They are not a sign of failure or concern, but they should also
not be ignored. Advise your clients to be vigilant about lapses (e.g.,
they stopped their daily walks for a few days because they felt down)
and, once recognized, to take the steps forward by continuing to prac-
tice skills in a self-​compassionate manner. This will ensure that their
gains are maintained and will provide them with a sense of control and
empowerment.

Lapses are different from relapses. During a lapse, levels of positive or

negative mood temporarily fluctuate, but during a relapse, they return
to pretreatment levels over days or weeks. Keeping a diary with mood
ratings is an effective way to distinguish between lapses and relapses.
While regular practice and review of how to deal with barriers can lower

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the risk of relapses, they can occur, even after a long time of remaining
symptom-​free. Discuss with your clients whether booster sessions are
available. If you do not offer them, provide your client with a referral list
of local providers. Emphasize that your client should not delay seeking
help, and that sometimes one or two booster sessions can be sufficient
to get back on track.

Finally, clients can be fearful or hesitant to continue practicing the

skills learned in treatment without being in therapy or working with a
therapist. Use the driver’s education model for therapy, with the client
as the driver and the therapist as the instructor. The therapist initially
provides significant support, but with time, the clients lead the therapy
by themselves, and the therapist provides less and less support. What
would happen if the instructor would continue to go everywhere with
the driver once they passed their driver’s test? Continued progress after
therapy ends is expected, and so are continued challenges. Assure your
clients that they are appropriately equipped to deal with most challenges
if they keep practicing the skills they have learned.

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Appendix

Client Exercises

This appendix contains a copy of each of the client exercise sheets. These exercises also appear in
the client workbook. Therapists and clients may photocopy the exercise sheets from their respec-
tive book, or they can download multiple copies at the Treatments That WorkTM website (www.
oxfordclinicalpsych.com/PAT).

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Exercise 2.1: Treatment Fit Assessment

Reward System to Target

Exercise to
Yes Wanting Liking Learning Practice

Are you having difficulty feeling

Labeling
positive emotions, Iike love, joy, □
Emotions
curiosity, pride, and excitement?

Do you have difficulty noticing Finding the

the positive in your day to day? □
Silver Linings

Do you tend to dismiss the

□ Gratitude
positive?

Do others tell you that you don’t Taking

give yourself enough credit? □
Ownership

Do you find yourself attributing

Taking
good things to Iuck rather than □
Ownership
your own doing?

Are you more Iikely to imagine

Imagining the
negative outcomes in the future □
Positive
than positive outcomes?

Have you stopped engaging in Actions Toward

pleasant or enjoyable activities? □
Feeling Better

Are you finding it hard to find

Savoring /​
pleasure in activities you once □
Generosity
enjoyed or think you should enjoy?

Do you have a hard time getting

motivated and excited about Designing
activities you once enjoyed or □ Positive
tasks that gave you a sense of Activities
accomplishment?

Have you struggled to feel

Appreciative
connected with others, including
□ Joy /​
emotions of empathy, Iove, or
Loving-​Kindness
compassion?

Clipart sourced from Microsoft PowerPoint.

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Exercise 2.2: Treatment Timing Assessment

Yes No

I can commit to completing practice assignments at home □ □

nearly every day (at least 3x/​week).

I am not engaging in another treatment that will interfere □ □

with my ability to engage in this treatment.

I am not experiencing elevations in other symptoms □ □

that take priority over this treatment (e.g., suicidality,
psychosis, mania, substance abuse).

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Exercise 4.1: A Mood Cycle You Noticed

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Exercise 4.2: Positive Emotions Dial

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Exercise 5.1: Daily Activity and Mood Record

DaiIy Activity and Mood Record

Instructions:
Monitor and record your daily activities throughout the day. Be sure to rate your mood
before and after each activity (0=​Iowest mood, 10=​highest mood). Try to record your
activities every day this week. Use a different DaiIy Activity and Mood Record for each day.

Day of the Week: ________________________

Activity Mood Before (0-​10) Mood After (0-​10)

1.00 ________________________________ _____________________ ___________________

2.00 ________________________________ _____________________ ___________________

3.00 ________________________________ _____________________ ___________________

4.00 ________________________________ _____________________ ___________________

5.00 ________________________________ _____________________ ___________________

6.00 ________________________________ _____________________ ___________________

7.00 ________________________________ _____________________ ___________________

8.00 ________________________________ _____________________ ___________________

9.00 ________________________________ _____________________ ___________________

10.00 ________________________________ _____________________ ___________________

11.00 ________________________________ _____________________ ___________________

12.00 ________________________________ _____________________ ___________________

13.00 ________________________________ _____________________ ___________________

14.00 ________________________________ _____________________ ___________________

15.00 ________________________________ _____________________ ___________________

16.00 ________________________________ _____________________ ___________________

17.00 ________________________________ _____________________ ___________________

18.00 ________________________________ _____________________ ___________________

19.00 ________________________________ _____________________ ___________________

20.00 ________________________________ _____________________ ___________________

21.00 ________________________________ _____________________ ___________________

22.00 ________________________________ _____________________ ___________________

23.00 ________________________________ _____________________ ___________________

24.00 ________________________________ _____________________ ___________________

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Exercise 5.2: Positive Activity List

Positive Activity List

Instructions: Review the Iist of positive activities. Identify whether each activity is a current
activity that brings you positive emotions, a past activity that brought on positive emotions, or a
new activity that you can try. Label each positive activity with C for current, P for past, or T for
trying something new. Add any additional activities that you currently enjoy, have enjoyed, or
think you might enjoy.

C, P, T C, P, T

_​_​_​_​_​__​ Taking a bath _​_​_​_​_​__​ Buying things for myself

_​_​_​_​_​__​ Going to a concert _​_​_​_​_​__​ Going to religious or community functions

_​_​_​_​_​__​ Going to a sports event _​_​_​_​_​__​ Going to class or club event

_​_​_​_​_​__​ Having lunch with friends or colleagues _​_​_​_​_​__​ Buying a gift for family or friends

_​_​_​_​_​__​ Going to bar, tavern, club, etc. _​_​_​_​_​__​ Donating to charity or volunteering

_​_​_​_​_​__​ Reading a book for pleasure _​_​_​_​_​__​ Making food or crafts to give away

_​_​_​_​_​__​ Playing with animals _​_​_​_​_​__​ Dancing to my favorite song

_​_​_​_​_​__​ Spending time in nature _​_​_​_​_​__​ Catching up with a friend

_​_​_​_​_​__​ Watching a movie, series, or sports _​_​_​_​_​__​ Being with children or grandchildren

_​_​_​_​_​__​ Going to a party _​_​_​_​_​__​ Helping others

_​_​_​_​_​__​ Hanging out with friends _​_​_​_​_​__​ Breathing fresh air

_​_​_​_​_​__​ Cooking _​_​_​_​_​__​ Playing video games with friends

_​_​_​_​_​__​ Thinking about a positive future _​_​_​_​_​__​ Playing a musical instrument

_​_​_​_​_​__​ Enjoying a favorite snack _​_​_​_​_​__​ Doing artwork (e.g., painting, photography)

_​_​_​_​_​__​ Cuddling with a significant other _​_​_​_​_​__​ Smelling my favorite candle scent

_​_​_​_​_​__​ Exercising, hiking, or playing sports _​_​_​_​_​__​ Playing cards or board games

_​_​_​_​_​__​ Exploring (e.g., going a new route) _​_​_​_​_​__​ Going on a waIk

_​_​_​_​_​__​ Putting on makeup, doing my hair, etc. _​_​_​_​_​__​ Writing a letter

_​_​_​_​_​__​ Dressing up in nice clothes _​_​_​_​_​__​ Looking at pictures

_​_​_​_​_​__​ Going to the movie theater _​_​_​_​_​__​ Gardening

_​_​_​_​_​__​ Watching funny movies or clips _​_​_​_​_​__​ Getting a manicure or pedicure

_​_​_​_​_​__​ Getting a massage _​_​_​_​_​__​ ______________________________________​

__​_​_​_​_​__​ ______________________________________​ _​_​_​_​_​__​ ______________________________________​

_​_​_​_​_​___​ ______________________________________​ _​_​_​_​_​__​ ______________________________________​

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Exercise 5.3: Positive Activity List Through Mastery

Positive Activity List through Mastery

Instructions: Review the list of positive activities that build mastery. Identify whether each
activity is a current activity that you are practicing, a past activity, or a new activity that
you can try. Label each activity with C for current, P for past, or T for trying something
new. Add any additional activities that currently bring on a feeling of mastery or that might
bring on that feeling.

C, P, T C, P, T

_​_​_​_​_​__​ Working towards meeting a deadline _​_​_​_​_​__​ Learning a musical instrument

_​_​_​_​_​__​ Learning a new skill (e.g., language) _​_​_​_​_​__​ Reading a book

_​_​_​_​_​__​ Finishing a project _​_​_​_​_​__​ Writing stories, novels, plays, or poetry

_​_​_​_​_​__​ Cleaning the dishes _​_​_​_​_​__​ Learning a new hobby (e.g., craft)

_​_​_​_​_​__​ Vacuuming _​_​_​_​_​__​ Redecorating a room

_​_​_​_​_​__​ Organizing _​_​_​_​_​__ ​Working on an application

_​_​_​_​_​__​ Planning trips or vacations _​_​_​_​_​__​ Restoring furniture or antiques

_​_​_​_​_​__​ Studying for an exam _​_​_​_​_​__​ Arranging songs or music

_​_​_​_​_​__​ Working on a jigsaw puzzle _​_​_​_​_​__​ Completing homework

__​_​_​_​_​__​ ______________________________________​ _​_​_​_​_​__​ ______________________________________​

_​_​_​_​_​_​__​ ______________________________________​ _​_​_​_​_​__​ ______________________________________​

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Exercise 5.4: My Positive Activity List

My Positive Activity List

Record: (1) activities that you currently find enjoyable, once found enjoyable, or believe
that you could find enjoyable, (2) activities that bring value to your life, and (3) activities
that may not bring immediate enjoyment but produce feelings of mastery (or other
positive emotions) following their completion. Rate the level of difficulty (0 – easy, 10 –
most difficult) for you to complete each item.

Activity DifficuIty (0–10)

1. _________________________________________________ ______________________________

2. _________________________________________________ ______________________________

3. _________________________________________________ ______________________________

4. _________________________________________________ ______________________________

5. _________________________________________________ ______________________________

6. _________________________________________________ ______________________________

7. _________________________________________________ ______________________________

8. _________________________________________________ ______________________________

9. _________________________________________________ ______________________________

10. _________________________________________________ ______________________________

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Exercise 5.5: Positive Activity Scheduling

Positive Activity Scheduling

Instructions:
Identify one new activity from your Positive Activity List that you can engage in this week.
Write this activity in the Activity box. Identify which category (e.g., social, work, health,
leisure, spirituality, other) the activity falls into. If your activity requires steps to complete it,
enter those steps in the How to Complete Activity box. Rate the difficulty level of each step
on a 0-​10 scale (0=​least difficult, 10=​most difficult). Then complete the paragraph, filling
in the number of times in the week, the days in the week, time of day, the duration, and
who you might be doing the activity with. Then, practice the activity throughout the week,
recording your mood before and after on a 0-​10 scale (0=​lowest mood, 10=​highest mood).
Also, record any positive emotions you may have noticed before, during, or after engaging
in the activity.

Activity How to Complete Activity

Steps DifficuIty (0-​10)
1. ______________________________ _______________
2. ______________________________ _______________
3. ______________________________ _______________

Category 4. ______________________________ _______________

5. ______________________________ _______________
⧠ Social ⧠ Leisure 6. ______________________________ _______________
⧠ Work ⧠ Spirituality 7. ______________________________ _______________
⧠ Health ⧠ Other 8. ______________________________ _______________

For homework, I will complete this activity _______ times this week, on ______________
(M, Tu, W, etc.) in the ______________ (morning, afternoon, evening) for ______________
(# of: sec, min, hrs) with __________________________________(name; if applicable).

Homework # Mood Before (0-​10) Mood After (0-​10) Positive Emotion(s)

1
2
3
4
5
6
7

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Exercise 5.6: Savoring the Moment

Savoring the Moment

Instructions: Identify and record a positive activity or event from this week. Recount the
event in your mind, Visualizing what you saw, heard, felt, thought, smelled, and tasted.
Record your level of mood (0=​Iowest mood, 10=​highest mood) before and after the
recounting, as well as the vividness of the recounting (10=​most vivid). Also, identify any
positive emotions you noticed, in addition to any other reactions (e.g., thoughts, physical
sensations).

Mood Mood
Before After Vividness Positive Reactions (thoughts,
Event (0-​10) (0-​10) (0-​10) Emotion(s) physical sensations)

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Exercise 6.1: Finding the Silver Linings

Finding the SiIver Linings

Instructions: Record the date of your practice. Then identify and record a positive,
negative, or neutral situation. Identify as many positive aspects (at least 6) of that
situation, and write them down under SiIver Linings. Don’t forget to write down your
mood before and after the exercise on a 0-​10 scaIe (0=​Iowest mood, 10=​highest mood).
Also, write down any positive emotions you experienced before, during, or after the
exercise. Try to complete one exercise a day.

Practice Date: ________________________________

Situation: ______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Silver Linings:

1 ______________________________________________________________________________________

2. _____________________________________________________________________________________

3. _____________________________________________________________________________________

4. _____________________________________________________________________________________

5. _____________________________________________________________________________________

6. _____________________________________________________________________________________

Mood Before Mood After

(0-​10) (0-​10) Positive Emotion(s)

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Exercise 6.2: Taking Ownership

Taking Ownership

Instructions: Record the date of your practice. Then identify and record a positive
situation. Identify as many positive aspects (at least 6) of that situation, and write
them down under Contributions. Don’t forget to write down your mood before and
after the exercise on a 0-​10 scaIe (0=​Iowest mood, 10=​highest mood). Also, write
down any positive emotions you experienced before, during, or after the exercise. Try
to complete one exercise a day.

Practice Date: ________________________________

Situation: ______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Contributions:

1. _____________________________________________________________________________________

2. _____________________________________________________________________________________

3. _____________________________________________________________________________________

4. _____________________________________________________________________________________

5. _____________________________________________________________________________________

6. _____________________________________________________________________________________

Mood Before Mood After

(0-​10) (0-​10) Positive Emotion(s)

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Exercise 6.3: Imagining the Positive

Imagining the Positive

Instructions: Identify a possible future event. Describe the future event with the best
possible outcome. Write it as if it were happening right now (present tense), using details
of your emotions, thoughts, and physical sensation (e.g., sight, smell, hearing).

Now imagine this vividly. Don’t forget to write down your mood before and after the
exercise on a 0-​10 scale (0=​Iowest mood, 10=​highest mood), as well as the vividness of
the recounting (10=​most vivid). Also, write down any positive emotions you experienced
before, during, or after the exercise. Try to complete one per day.

Mood Before (0-​10) Mood After(0-​10) Vividness (0-​10) Positive Emotion(s)

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Exercise 7.1: Loving-​Kindness

Loving-​Kindness

Instructions: Record the date of your practice. Identify at Ieast one recipient of your
Loving-​Kindness practice. It can be helpful to start with someone uncomplicated. Read
or listen to the Loving-​Kindness script or recording. Be sure to record your mood (0=​
lowest mood, 10=​highest mood) before and after your practice, as well as any positive
emotions, thoughts, or physical sensations you notice. Try to complete one per day.

Practice Date: _________________________________________________________________________

Recipient(s) of Practice: _______________________________________________________________

Mood Before (0-​10): ___________________________________________________________________

Mood After (0-​10): _____________________________________________________________________

Positive Emotion(s): ___________________________________________________________________

_________________________________________________________________________________________

Reaction (thoughts, physical sensations):

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_________​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_________​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_________​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_________​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Exercise 7.2: Gratitude

Gratitude

Instructions: Record the date of your practice. List 5 things you notice and appreciate
each day, making sure that they are different from the previous day. Record your mood
(0=​lowest mood, 10=​highest mood) before and after making the list. Also, write down
any positive emotions you notice. Try to complete one exercise per day.

Date: _________________

Today I am grateful for...

1. _____________________________________________________________________________________

2. _____________________________________________________________________________________

3. _____________________________________________________________________________________

4. _____________________________________________________________________________________

5. _____________________________________________________________________________________

Mood Before (0-​10): ___________________________________________________________________

Mood After (0-​10): _____________________________________________________________________

Positive Emotion(s): ___________________________________________________________________

_________________________________________________________________________________________

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Exercise 7.3: Generosity

Generosity

Instructions: Record the date and time of your generous act. Identify and record what
your generous act will be and who will be the recipient of it. Record your mood (0=​
lowest mood, 10=​highest mood) before and after doing the generous act. Also, write
down any positive emotions you notice. Try to complete 3 per week.

Date/​Time: ____________________________________________________________________________

Act: ____________________________________________________________________________________

Recipient: _____________________________________________________________________________

Mood Before (0-​10): __________________________________________________________________

Mood After (0-​10): ____________________________________________________________________

Positive Emotion(s): ___________________________________________________________________

________________________________________________________________________________________

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Exercise 7.4: Appreciative Joy

Appreciative Joy

Instructions: Record the date of your practice. Identify at Ieast one recipient of your
Appreciative Joy practice. It can be helpful to start with someone uncomplicated. Read
or listen to the Appreciative Joy script or recording. Be sure to record your mood (0=​
Iowest mood, 10=​highest mood) before and after your practice, as well as any positive
emotions, thoughts, or physical sensations you notice. Try to complete one practice per
day.

Practice Date: _________________________________________________________________________

Recipient(s) of Practice: _______________________________________________________________

Mood Before (0-​10): ___________________________________________________________________

Mood After (0-​10): _____________________________________________________________________

Positive Emotion(s): ___________________________________________________________________

Reaction (thoughts, physical sensations):

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Exercise 8.1: My Progress Assessment

Overall Treatment Evaluation: Positive Mood

1. Has your overall mood improved since the start of treatment?
2. Are you feeling positive emotions more frequently? Are you noticing more positive
emotions throughout your day or week? Do you feel certain positive emotions more
intensely?

Overall Treatment Evaluation: Negative Mood

3. What about your negative mood?

Treatment Evaluation: Core Components

Chapter 5: Actions Toward Feeling Better
4. Are you engaging in more meaningful activities? Are you able to savor the activities
that you already engage in?
5. Have you been incorporating more positive activities throughout your day and week?

Chapter 6: Attending to the Positive

6. Are you noticing silver linings every day?
7. Are you giving yourself credit for things you did well? Are you accepting praise without
dismissing it? Are you attributing some positive events to your own doing?
8. Are you taking time to imagine future events positively?

Chapter 7: Building Positivity

  9. Are you having more loving and kind feelings toward yourself and others?
10. Are you noticing feeling joy from the successes and joy of others?
11. Are you feeling more grateful each day, even during times of stress?
12. Are you more generous to others or yourself? Have you been engaging in even tiny
acts of generosity (e.g., kindness, helping hand, a listening ear, advice) a few times
a week?

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Exercise 8.2: My Long-​Term Goals

My Long-​Term Goals

Instructions: Identify at least 1-​3 goals that you have for after treatment. What was this
treatment in service of? Why did you want to improve your mood? Identify any steps
that you need to take to meet each goal. Identify one of the skills from this treatment as
a step towards meeting one of your goals.

My long-​term goals are...

1. _____________________________________________________________________________________

Step 1. ____________________________________________________________________________

Step 2. ____________________________________________________________________________

Step 3. ____________________________________________________________________________

2. _____________________________________________________________________________________

Step 1. ____________________________________________________________________________

Step 2. ____________________________________________________________________________

Step 3. ____________________________________________________________________________

3. _____________________________________________________________________________________

Step 1. ____________________________________________________________________________

Step 2. ____________________________________________________________________________

Step 3. ____________________________________________________________________________

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Exercise 8.3: Maintaining My Gains

Maintaining My Gains

Instructions: Answer each of these questions. Identify how you will maintain your gains
in treatment through skills from Actions Toward FeeIing Better‚ Attending to the Positive,
and Building Positivity.

How will I maintain my gains through Actions Toward FeeIing Better?

1._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

2._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

3._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

How will I maintain my gains through Attending to the Positive?

1._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

2._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

3._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

How will I maintain my gains through Building Positivity?

1._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

2._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

3._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Exercise 8.4: Overcoming Barriers

Overcoming Barriers

Instructions: Identify possible barriers that might interfere with you meeting one of your
long-​term goals. List 1-​3 steps you can take to avoid that barrier.

Barriers...

1. _____________________________________________________________________________________

Step 1. _____________________________________________________________________________

Step 2. _____________________________________________________________________________

Step 3. _____________________________________________________________________________

2. _____________________________________________________________________________________​

Step 1. _____________________________________________________________________________

Step 2. _____________________________________________________________________________

Step 3. _____________________________________________________________________________

3. _____________________________________________________________________________________

Step 1. _____________________________________________________________________________

Step 2. _____________________________________________________________________________

Step 3. _____________________________________________________________________________

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Recommended Readings

Auerbach, R. P., Pagliaccio, D., & Pizzagalli, D. A. (2019) Toward an

improved understanding of anhedonia. JAMA Psychiatry, 76(6),
571–​573.
Craske, M. G., Meuret, A., Ritz, T., Treanor, M., & Dour, H. (2016).
Treatment for anhedonia: A neuroscience-​driven approach. Depression
and Anxiety, 33(10), 927–​938.
Craske, M. G., Meuret, A., Ritz, T., Treanor, M., Dour, H., & Rosenfield,
D. (2019). Positive affect treatment for depression and anxiety: A
randomized clinical trial for a core feature of anhedonia. Journal of
Consulting and Clinical Psychology, 87(5), 457–​471.
Vinograd, M., & Craske, M. G. (2020). Using neuroscience to augment
behavioral interventions for depression. Harvard Review of Psychiatry,
28(1), 14–​25.

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About the Authors

Michelle G. Craske, PhD, is Professor of Psychology, Psychiatry and

Biobehavioral Sciences, Miller Endowed Term Chair, Director of the
Anxiety and Depression Research Center, and Associate Director of
the Staglin Family Music Center for Behavioral and Brain Health,
at the University of California, Los Angeles. She is also co-​director
of the UCLA Depression Grand Challenge. She has researched and
published extensively in the area of fear, anxiety, and depression and
is on the Web of Science Most Highly Cited Researcher List. She
has been the recipient of extramural funding for research projects
pertaining to risk factors for anxiety and depression among children
and adolescents, neural mediators of emotion regulation and behav-
ioral treatments for anxiety disorders, fear extinction translational
models for optimizing exposure therapy, novel behavioral therapies
targeting reward sensitivity and anhedonia, and scalable treatment
models for underserved populations. She has received multiple awards
of distinction. At UCLA, she received the Society of Postdoctoral
Scholars at UCLA Mentorship Award and Career Development Award.
Nationally, she received the American Psychological Association
Society for a Science of Clinical Psychology Distinguished Scientist
Award, the Outstanding Researcher Award from the Association for
Behavioral and Cognitive Therapy, and the Aaron T. Beck Award
from the Academy of Cognitive Therapy. Internationally, she was
awarded the International Francqui Professorship from Belgium, and
the Eleonore Trefftz Guest Professorship Award from the Technical
University of Dresden, Germany. She received an honorary doctorate
from Maastricht University, Netherlands, and is an honorary fellow
of the Department of Psychiatry, Oxford University, and an honorary
fellow of the Dutch-​Flemish Postgraduate School for Research and
Education. Further, she has been president of the APA Society for
a Science of Clinical Psychology and the Association for Behavioral
and Cognitive Therapy. She is Editor-​in-​Chief for Behaviour Research

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and Therapy. Dr. Craske received her BA Hons from the University of
Tasmania and her PhD from the University of British Columbia.

Halina J. Dour, PhD, is the owner of the Center for Genuine Growth,
a multi-​state telepsychology practice. Dr. Dour spent most of her post-
doctoral career within Veterans Affairs (VA) healthcare systems. She
served as the Eating Disorder Team Coordinator and as a member of the
PTSD Clinical Team within the Orlando VA Healthcare System. Prior
to this, she spent nearly two years as a clinical psychologist in the Mental
Health Clinic and Intensive Outpatient Program at the VA Puget Sound,
Seattle Division. Dr. Dour has been trained in numerous evidence-​
based treatments and worked in a variety of settings. This, coupled with
a passion for creating interventions, therapy materials, and program-
ming, has led Dr. Dour to gain a specific expertise in treatment and
program development. She has served, and continues to serve, as a con-
sultant on multiple treatment development projects. Dr. Dour received
her bachelor’s degree cum laude in psychology from Wellesley College
and her PhD in Clinical Psychology from the University of California,
Los Angeles, where she studied under the mentorship of Dr. Michelle
Craske. During her doctoral training, she earned numerous awards and
fellowships, including the National Science Foundation Fellowship,
the University Distinguished Fellowship, the Ursula-​Mandel Stipend
Award, the Philip & Aida Siff Award, the UCLA Affiliates Award,
the Senior Clinical Scientist Award, the Outstanding SSCP Student
Clinician Award, and the APA Div12 Distinguished Student Practice in
Clinical Psychology Award. Dr. Dour completed her predoctoral intern-
ship at the VA Sepulveda Ambulatory Care Center and her postdoctoral
fellowship at the VA Puget Sound, Seattle Division.

Michael Treanor, PhD, is an Assistant Project Scientist with the

UCLA Anxiety and Depression Research Center. His research focuses
on improving exposure therapy for posttraumatic stress disorder and
anxiety-related disorders, and he has extensive experience in numerous
evidence-based treatments for PTSD, anxiety disorders, and mood
disorders, including mindfulness practices. Along with Dr. Dour and Dr.
Craske, he developed the original content of Positive Affect Treatment.
Dr. Treanor is a principal investigator and clinical supervisor for ongoing
psychological treatment trials at the UCLA Anxiety and Depression
Research Center and provides therapist training in evidence-based

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therapies, including Positive Affect Treatment, for psychiatry and psy-

chology fellows. Dr. Treanor completed an APA-approved internship
at the National Center for PTSD, Behavioral Science Division at the
Boston VA, and a National Institute of Mental Health T32 postdoctoral
fellowship at UCLA.

Alicia E. Meuret, PhD, is a Professor at the Department of Psychology

at Southern Methodist University (SMU), the Director of the SMU
Anxiety and Depression Research Center, and a licensed clinical psy-
chologist. She completed her doctoral studies at Stanford University
Department of Psychiatry and Behavioral Sciences and her postdoctoral
studies at the Affective Neuroscience Laboratory at Harvard University
and the Center for Anxiety and Related Disorders at Boston University.
Her research program focuses on novel treatment approaches for anx-
iety and mood disorders, biomarkers in anxiety disorders and chronic
disease (asthma), fear extinction mechanisms of exposure therapy, and
mediators and moderators in individuals with affective dysregulations,
including non-​ suicidal self-​
injury. Dr. Meuret is the founder of
Capnometry-​Assisted Respiratory Training (CART). Dr. Meuret has
published over 100 scientific publications and authored over 200 con-
ference presentations. Her work has received ongoing funding from
the National Institutes of Health and other funding agencies. She has
received multiple honors, including from the Anxiety and Depression
Association of America, the Psychiatric Research Society, and the
American Psychosomatic Society. She is a Beck Institute Fellow and
a Rotunda Outstanding Professor. Dr. Meuret is a member of the
Scientific Advisory Board of the Anxiety and Depression Association
of America, was past president of the International Society of the
Advancement of Respiratory Psychophysiology, and is a fellow of the
Association of Cognitive and Behavioral Therapies. As a technical ex-
pert, she assisted the Agency for Healthcare Research and Quality
Effective Health Care Program and was on the Scientific Advisory Board
of the Centre for Excellence at the University of Leuven, Belgium.
Dr. Meuret serves on several editorial boards and was an Associate Editor
for Behavior Therapy. Dr. Meuret has more than 20 years of clinical ex-
perience treating patients with emotional disorders.

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