People living with severe mental disorders such as schizophrenia or bipolar disorder often receive treatment focused primarily on managing symptoms, yet research suggests that improvements in functioning do not automatically translate into a better quality of life. A new pilot study tested a 15-session group programme called Think and Cope Positively (TC+), finding that it was both feasible and well-received among adults with these diagnoses, with participants showing statistically significant gains in life satisfaction, self-acceptance, and optimism after completing the course. The research, published in Psychiatric Rehabilitation Journal, suggests that targeting subjective well-being directly, rather than relying solely on symptom reduction, may be a valuable addition to psychosocial rehabilitation. The findings provide early support for scaling TC+ into larger controlled trials.
Severe mental disorders (SMDs) are defined by three criteria: a qualifying diagnosis (such as schizophrenia spectrum disorders, bipolar disorder, or psychotic depression), significant impairment in day-to-day functioning, and a duration of more than two years. Psychosocial rehabilitation for this population has historically concentrated on stabilising deficits and improving functioning. Yet evidence has accumulated to suggest that well-being, both hedonic (encompassing pleasure and happiness) and eudaimonic (centred on realising personal potential and living with purpose), does not simply follow from symptom control.
Rocio Caballero of the Department of Psychology at Pontificia Comillas University in Madrid, along with colleagues from Universidad Complutense de Madrid, designed TC+ to fill this gap. The programme integrates three evidence-based frameworks: positive psychology interventions (PPIs), cognitive behavioural therapy (CBT), and acceptance and commitment therapy (ACT). Its 15 sessions are organised into six modules progressing from hedonic content, such as cultivating positive emotions, to eudaimonic themes including developing a sense of life purpose and coping strategies.
Participants were recruited through convenience sampling from public ambulatory mental health services in the Community of Madrid, Spain. To be eligible, individuals had to be aged 18 to 65, carry a primary diagnosis of SMD (schizophrenia, bipolar disorder, personality disorder, or obsessive-compulsive disorder), and express interest in a well-being-focused group. Those with severe formal thought disorders, limited cognitive resources, or active substance dependence were excluded. A total of 27 people were initially referred; one withdrew before baseline assessment, leaving 26 who entered the study. Of those, 20 completed the full programme, representing a 77% completion rate across four separate treatment groups of five to eight participants each.
Six therapists, predominantly psychologists with an average of 7.3 years’ experience, delivered the weekly 75-minute group sessions after receiving five hours of training on the TC+ protocol. Each participant was assigned a support person, such as a family member, friend, or trusted professional, who attended the final session. Participants could voluntarily make up any missed sessions before the following one, either individually or in small groups.
Outcomes were assessed immediately before and after the 15-week programme using validated self-report measures. Hedonic well-being was captured by the Satisfaction with Life Scale (SWLS), a five-item instrument. Eudaimonic well-being was measured through the Scales of Psychological Well-being, which covers dimensions including self-acceptance, purpose in life, personal growth, positive relationships, and autonomy. General well-being was tracked session by session using the Warwick Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes included optimism, measured by the Openness to the Future Scale, and therapeutic alliance, measured by the Working Alliance Theory of Change Inventory. Symptom severity was assessed using the Symptom Checklist-45 (SCL-45). Because the outcome variables deviated significantly from a normal distribution, the team used non-parametric tests throughout, specifically the Wilcoxon signed-rank test for pre-to-post comparisons.
Feasibility indicators were strong. Although participants attended an average of 10.8 sessions out of 15, the option to make up missed content brought the comprehensive attendance rate to 14 out of 15 sessions (93.3%). Of the 20 completers, 13 attended every session without missing any at all. In-session exercise completion stood at 79.6%, while homework completion outside sessions was more modest at 43.5%.
Participants rated the therapists as highly competent (mean rating 9.4 out of 10) and expressed a strong willingness to recommend the programme to others (mean rating 9.4). Therapists, for their part, reported that session goals were achievable and that the group format was practical to implement without additional resources.
Outcome results showed significant pre-to-post improvements in four of the five measured well-being domains. Life satisfaction increased with a large effect size (d = 0.84), and general well-being improved similarly (d = 0.87). Self-acceptance showed the largest effect among eudaimonic subscales (d = 0.93), and purpose in life also improved significantly (d = 0.65). Three subscales, specifically positive relationships with others, autonomy, and personal growth, did not reach statistical significance, though descriptive trends were positive. Optimism improved significantly (d = 0.69), and therapeutic alliance strengthened over the course of treatment (d = 0.44). Session-by-session tracking of WEMWBS scores revealed a clear positive linear trend across all 15 sessions (Kendall’s τb = .794, p < .001 among 14 participants with complete session data), suggesting cumulative benefit rather than a single-point shift.
On the clinical side, no participant showed any worsening in any symptom domain. The programme was associated with a statistically significant reduction in global symptom severity (d = -0.43), depression (d = -0.42), and interpersonal sensitivity (d = -0.45). Anxiety, somatisation, and several other symptom dimensions showed descriptive improvements that did not reach significance in this small sample.
The study carries important limitations. Most critically, the absence of a control group means the pre-to-post changes cannot be attributed specifically to TC+. Without a waitlist or treatment-as-usual comparison, regression to the mean, natural recovery, or non-specific therapeutic factors cannot be ruled out as explanations. The sample of 20 completers is small, limiting statistical power and the reliability of effect size estimates. Self-report measures raise concerns about social desirability bias, particularly in a context where participants know the researchers and facilitators personally. The authors note that self-report has acceptable validity for this population in the literature, but supplementary observational or objective assessments would strengthen future work.
A practical limitation also emerged around the support person element. Although nine participants brought a support person to the final session, the remaining seven attended without accompaniment, with several reporting feelings of loneliness as a result. The researchers note that fear of rejection was among the reasons given for not inviting someone, pointing to a design challenge for future iterations.
The authors suggest that several features of TC+ may account for the effect magnitudes observed: the programme is longer (15 sessions) than comparable well-being interventions, which typically run to 10 or 11 sessions, and the session-by-session data support a cumulative dose-response pattern. The integration of CBT, PPI, and ACT components may produce combined benefits beyond any single modality. Looking forward, Caballero and colleagues call for randomised controlled trials with larger samples to establish whether these gains hold against active comparison conditions, to examine moderators such as diagnosis subtype and symptom severity, and to determine how long improvements in life satisfaction and purpose are maintained beyond the final session.
The study, “Think and Cope Positively: A Feasibility and Acceptability Study to Improve the Subjective Well-Being of People Affected by a Severe Mental Disorder,” was authored by Rocio Caballero, Vanesa Peinado, Carmen Valiente, Ana Vucic, Alvaro Alonso, and Jose Manuel Caperos.
