If we accept the possibility that a treatment which is helpful on average may be ineffective in some cases and even harmful in someone else, we may learn that a given therapy may not be of value for a particular class or subgroup of subjects who present with certain clinical characteristics [1]. Big Pharma, which together with biotechnology corporations substantially controls medical publications and information [2], does not like to hear about the subgroup which gets worse, probably because it may scare potential customers. Yet these events occur with any drug. I have studied the paradoxical reactions that may take place with antidepressant drugs (when medications deepen the depressed mood) [3]. Clinical worsening may also occur with psychotherapy. The various psychotherapy schools also do not like to hear about negative effects [4].
In clinical pharmacology, adverse events may be due to the fact that the physician did not prescribe the drug appropriately (e.g., at a dosage that is excessive or inadequate); however, in this case treatment was correct. In psychotherapy, negative effects may arise because of psychotherapy that is not properly conducted [4]. However, in the case of Tom, I knew the psychologist who used CBT and held him in high regard for his competence and skills, particularly in obsessive-compulsive disorder. I thus felt that every reasonable approach had been attempted. What could I do that was different? I thought on the substantial distinction that Tom made: drugs did not help him, while psychotherapy made him worse.
I formulated a hypothesis. The basic mechanism of cognitive therapy lies in monitoring distress: identification of the situations where it occurs leads to finding the negative thinking (automatic thoughts) that is associated and precedes the negative emotions (fig. 1). Yet, in the case of Tom, this mechanism probably leads to deepening of distress. What about doing the opposite: monitoring well-being and looking at what interrupts it (fig. 2)? So I told Tom that he had to keep a diary where he should report the instances of well-being. I did not provide any definition of well-being, but I asked him to write down the situations when he felt good, what he experienced, and its intensity. His comment was not encouraging: ‘It will be a blank diary.’
Fig. 1. Basic mechanism of cognitive therapy.
Fig. 2. Basic mechanism of Well-Being Therapy.
Second Session
When he came back, he had his diary. He had written a few instances of well-being. He reluctantly acknowledged that they were present, but added ‘they were extremely short, a few minutes only’. Table 1 illustrates one of these instances. I was surprised to see that, even in the midst of distress and suffering, there were some good times, although they were brief. Tom was then instructed to report also which thoughts led to a premature interruption of these instances of well-being. Again I did not share with him information about the type of thoughts we were looking for (automatic thoughts) and the potential explanations that could be made. I wanted him to develop his own antidote.
I did, however, write down in his diary a few things (I always write in the diaries of my patients: instructions for taking medications, behavioral assignments, things we discussed in the session that I feel important). I asked him to go back to the university every other day and to select one exam to be taken. He complained, ‘It makes no sense. I am no longer able to study.’ I replied that gradually we would have come back to it, and I shared with him the story of when I broke my leg while skiing at the age of 11. It was a bad fracture and the orthopedic surgeon applied a cast. I had to keep it for three and a half months, without ever standing up. Finally the day came when my cast had to be taken off, and I thought my agony would be over. My parents did not tell me anything; I thought that my bone had been fixed and I could get up and run. When the surgeon removed the cast, I discovered it was not true at all: my leg had no muscle, I could not bend the knee and when I tried to stand up I realized I was not able to. I started crying, saying that my life was ruined and that I could no longer walk. I do not know whether the clinical choice of the surgeon had been the best also in those days, but his response was:
Table 1. Second session
| Situation | Feeling of well-being | Intensity (0-100) |
| Late afternoon.I am at home studying.Laura will be coming soon. | I am happy to see her. | 40 |
Do not cry, Giovanni. It is the way it should be. Now you should start doing some exercise [he just gave me a couple of hints; there was no physical therapy in the place where I lived]. But remember: some days you will feel that you are making progress, that you can bend your knee a little more than the previous days. Other days, you will feel that it is getting worse, that you bend your knee less. Do not worry. Keep on doing what I told you. You will run again.
This is what happened and I often share this story with patients. Therapist self-disclosure was found in psychotherapy research to lower patient distress [5], and I have always felt that it is important for a physician to transmit both technical and emotional knowledge.
Third Session
Tom came back 2 weeks later with his diary. Table 2 displays one example of the situations he wrote.
Table 2. Third session
| Situation | Feeling of well-being | Interrupting thoughts |
| Morning. I am at home studying. | I was able to study well for one entire hour. | Now something will happen to spoil your morning → obsession. |
I must say that I did not know what to expect. Tom was a bright, well-educated, and sensitive young man. I wanted to see whether, with some simple indications (as my orthopedic surgeon), he could develop his way to recovery. Indeed he had identified not only feelings of well-being, but what interrupted those feelings. I was using the framework of rationale-emotive and cognitive therapies, and I decided then to opt for the cognitive schema. I thus explained to him what automatic thoughts are [6]. I used Aaron Beck's description [6]. They often occur in specific situations and do not arise as a result of reasoning or reflection, but by reflex. They are relatively autonomous: the subject makes no effort to initiate them and often has troubles turning them off