Should Therapy Target Positive or Negative Emotions?

STUDY: Meuret AE et al, JAMA Netw Open 2026;9(4):e267403

STUDY TYPE: Randomized clinical trial
FUNDING: National Institute of Mental Health

Background

Standard psychotherapy for depression and anxiety focuses on reducing negative thoughts and emotions. This trial tested whether directly targeting reward processing — the brain’s capacity to want, enjoy, and learn from positive experience — could outperform that approach.

The Study

• 98 adults with severely low positive affect plus moderate-to-severe depression or anxiety.
• Randomized to positive affect treatment (PAT) or negative affect treatment (NAT), a well-designed comparison condition drawn from standard cognitive behavioral therapy, both as 15 weekly telehealth sessions

The positive approach (PAT) was built around three reward processes:

1. Anticipating pleasure
2. Savoring it in the moment
3. Learning to connect behavior with positive mood

Overall clinical status — a composite of positive affect (PANAS-P), depression and anxiety symptoms (DASS-21), and interviewer-rated anhedonia — improved more with PAT than NAT during treatment (effect size d = 0.27) and at one-month follow-up (d = 0.21). The advantage was driven largely by greater reductions in depression and anxiety on the DASS-21 (d = 0.55).

Positive affect scores and interviewer-rated anhedonia improved in both groups but didn’t differ significantly between them, a surprise, as PAT was originally designed to target anhedonia. The authors speculate that fully virtual delivery may have blunted PAT-specific gains, since showing up in person for therapy may itself engage reward motivation.

Practice Implications

1. Focusing on positive experiences had a modest advantage, and there’s a manual available for PAT.
2. Caution: Some patients find it invalidating, “I can’t feel anything positive!” Particularly those with chronic depression.