Wintering Well: A Therapist Guide to Pre-Emptive Work for Seasonal Affective Disorder and the Winter Dip

Depression · Practice-informed · Practice-informed

A six-session pre-emptive protocol for adults with a winter pattern, to begin in early October. It uses the CBT for seasonal affective disorder model, in which winter depression is maintained by reduced light, altered sleep timing, withdrawal and seasonal beliefs, then adds compassion-focused work, ACT values work and two breathing techniques introduced in stages. The overall evidence level is practice-based because the combination has not been trialled in seasonal depression, although its CBT-SAD core is better supported.

Underlying mechanism: Pre-Emptive Integrative Protocol for Seasonal Affective Disorder: CBT-SAD Foundations, CFT, ACT and Breathwork

What it helps with

  • Using the one time of year when a client with a winter history is usually well enough to learn and rehearse skills, before low mood makes learning hard.
  • Giving clinician and client a shared picture of the winter loop: less light, a slower body, withdrawal, the inner critic, seasonal beliefs and a sinking mood.
  • Building a personal plan for light, rhythm, breath, values-based activity and early warning, so that the client is better prepared, quicker to notice and kinder in response.
  • Supporting recurrence prevention across winters, which the largest trial of CBT for seasonal affective disorder identified as the central challenge.
  • Offering a late-start route and a January booster so the plan is tested against the winter the client actually has.

How clinicians use it

  • Screen for risk and for any history of elevated mood first, and take a baseline measure such as the PHQ-9 or your usual routine outcome measure.
  • Run the sessions in order, keeping the compassion-focused session (4) before the values session (5) so that self-criticism is softened first.
  • Teach nose-low-slow breathing first, and offer resonance breathing at 5 seconds in and 5 out only later as an optional second technique.
  • Use the Winter Watch micro-tool for the clock-change bridge and the weekly early-warning check-in, and review it at the booster.
  • Treat every rating as a conversation starter and not a verdict.

Clinical Implementation Guide

  1. Ask about elevated or irritable mood and assess risk before any light advice, and confirm the GP is aware of any light box.
  2. Start in early October if you can. If a client begins after the clocks change, compress sessions 1 to 3 into two meetings.
  3. Keep the compassion-focused session (4) before the ACT values session (5).
  4. Book the January booster before the client leaves session 6 and plan next autumn at that review.

What the worksheet looks like

Therapist Guide: Wintering Well — worked example
SessionFocusWorksheet
1Understanding your winter: personal timeline, the winter loop, seasonal beliefs, goals and a bipolar screenW1
2Light, sleep and rhythm: morning light plan, optional light box discussion and the clock-change bridgeW2
3Breath and calming the body: nose-low-slow breathing, cue anchors and optional resonance breathingW3
4The winter self-critic: three systems, critic mapping and the compassionate winter friendW4
5Values and winter anchors: defusion from seasonal beliefs, clarifying values and a floor plan for low daysW5
6Early warning and action plan: warning signs, traffic-light plan, support people and key datesW6

Clinical cautions

Assess risk at every session; low winter mood can include suicidal thoughts and Worksheet 6 is not a safety plan. Ask about bipolar spectrum history before any light advice. Light boxes need a GP or pharmacist check, especially with eye conditions, light-sensitising medication or migraine. If the client already meets criteria for a current episode, this is no longer pre-emptive and the usual depression pathway applies. Consider thyroid problems, anaemia and other medical contributors. Never use breath holds, and stop if the client is dizzy or anxious. Pace the CFT work because fear of compassion is common. The overall evidence rating is practice-based, the lowest tier present: the pre-emptive adaptation, the third-wave layers and the breath techniques have not been trialled together or in seasonal depression. Adults only.

References

  1. A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36. https://doi.org/10.1159/000365764
  2. Chen, Z.-W., Zhang, X.-F., & Tu, Z.-M. (2024). Treatment measures for seasonal affective disorder: A network meta-analysis. Journal of Affective Disorders, 350, 531-536. https://doi.org/10.1016/j.jad.2024.01.028
  3. Donnelly, D., Georgiadis, E., & Stavrou, N. (2023). A meta-analysis investigating the outcomes and correlation between heart rate variability biofeedback training on depressive symptoms and heart rate variability outcomes versus standard treatment in comorbid adult populations. Acta Biomedica, 94(4), e2023214. https://doi.org/10.23750/abm.v94i4.14305
  4. Galin, S., Nagy, L., Turan, C., Laczko, D., Szabo, B., Hegyi, P., Molnar, Z., & Keri, S. (2026). Heart rate variability as a predictor of future depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 403, 121388. https://doi.org/10.1016/j.jad.2026.121388
  5. Golden, R. N., Gaynes, B. N., Ekstrom, R. D., Hamer, R. M., Jacobsen, F. M., Suppes, T., Wisner, K. L., & Nemeroff, C. B. (2005). The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 162(4), 656-662. https://doi.org/10.1176/appi.ajp.162.4.656
  6. Han, A., & Kim, T. H. (2023). Effects of self-compassion interventions on reducing depressive symptoms, anxiety, and stress: A meta-analysis. Mindfulness, 14(7), 1553-1581. https://doi.org/10.1007/s12671-023-02148-x
  7. Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. https://doi.org/10.3389/fpsyg.2014.00756
  8. Millard, L. A., Wan, M. W., Smith, D. M., & Wittkowski, A. (2023). The effectiveness of compassion focused therapy with clinical populations: A systematic review and meta-analysis. Journal of Affective Disorders, 326, 168-192. https://doi.org/10.1016/j.jad.2023.01.010
  9. National Health Service. (2025). Seasonal affective disorder (SAD) [Web page, last reviewed 17 December 2025]. https://www.nhs.uk/mental-health/conditions/seasonal-affective-disorder-sad/
  10. Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B., Farrand, P. A., Gilbody, S., Kuyken, W., O'Mahen, H., Watkins, E. R., Wright, K. A., Hollon, S. D., Reed, N., Rhodes, S., Fletcher, E., & Finning, K. (2016). Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): A randomised, controlled, non-inferiority trial. The Lancet, 388(10047), 871-880. https://doi.org/10.1016/S0140-6736(16)31140-0
  11. Rohan, K. J., Burt, K. B., Norton, R. J., Perez, J., Iyiewuare, P., & Terman, J. M. (2023). Change in seasonal beliefs mediates the durability advantage of cognitive-behavioral therapy over light therapy for winter depression. Behavior Therapy, 54(4), 682-695. https://doi.org/10.1016/j.beth.2022.11.002
  12. Rohan, K. J., Lindsey, K. T., Roecklein, K. A., & Lacy, T. J. (2004). Cognitive-behavioral therapy, light therapy, and their combination in treating seasonal affective disorder. Journal of Affective Disorders, 80(2-3), 273-283. https://doi.org/10.1016/S0165-0327(03)00098-3
  13. Rohan, K. J., Meyerhoff, J., Ho, S.-Y., Evans, M., Postolache, T. T., & Vacek, P. M. (2016). Outcomes one and two winters following cognitive-behavioral therapy or light therapy for seasonal affective disorder. American Journal of Psychiatry, 173(3), 244-251. https://doi.org/10.1176/appi.ajp.2015.15060773
  14. Vann-Adibe, S., Tsui, H. K. H., Zhou, H. Q., Ciren, Z., Li, C., & Cha, S. K. W. (2026). Efficacy and methodology of remote heart rate variability biofeedback interventions for mental health: A systematic review and meta-analysis. Applied Psychophysiology and Biofeedback, 51(3), 441-452. https://doi.org/10.1007/s10484-025-09750-w
  15. Wan, Y., Ding, J., Fan, M., & Huang, H. (2025). Effectiveness of visible light for seasonal affective disorder: A systematic review and network meta-analysis. Medicine, 104(27), e43107. https://doi.org/10.1097/MD.0000000000043107

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Wintering Well

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