References
1 Horwitz RI, Singer BH, Makuch RW, Viscoli CM: Can treatment that is helpful on average be harmful to some patients? J Clin Epidemiol 1996;49:395-400.
2 Abramson J: Overdosed America. New York, Harper, 2005.
3 Fava GA: Do antidepressant and antianxiety drugs increase chronicity in affective disorders? Psychother Psychosom 1994;61:125-131.
4 Linden M: How to define, find and classify side effects in psychotherapy. Clin Psychol Psychother 2013;20:286-296.
5 Barrett MS, Berman J: Is psychotherapy more effective when therapists disclose information about themselves? J Consult Clin Psychol 2001;69:597-603.
6 Beck AT: Cognitive Therapy and the Emotional Disorders. New York, International Universities Press, 1976.
7 Engel GL: ‘Psychogenic’ pain and the pain-prone patient. Am J Med 1959;26:899-918.
8 Jahoda M: Current Concepts of Positive Mental Health. New York, Basic Books, 1958.
9 Ryff CD: Happiness is everything, or is it? Explorations on the meaning of psychological well-being. J Pers Soc Psychol 1989;6:1069-1081.
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The Process of Validation of Well-Being Therapy
After finding a well-being-enhancing strategy, I realized that several steps were necessary to go further. Even though the first case involved a case of an acute invalidating obsessive-compulsive disorder, the area where I wanted to apply these methods was the residual phase of mood and anxiety disorders, particularly as to relapse prevention. The methodology that I needed to use had to be that of controlled investigations, as Robert Kellner had taught me. I had to involve my research group, i.e., the people who had believed in me and in my odd ideas.
A characteristic of the studies I am going to describe is that they did not involve large populations (in Italy research funding is minimal), but were very careful in assessment and methodology. I personally knew each patient who was involved. The data were expressed by numbers, but I had in mind the actual patients, their faces, and our encounters. The first question was whether patients who were judged to be remitted upon pharmacological and/or psychological treatment from their mood or anxiety disorders displayed less well-being compared to healthy controls who were never ill.
Carol Ryff [1] had developed a questionnaire, the Psychological Well-Being Scales (PWB) for measuring psychological well-being. In those years, however, there was no information as to its application to clinical populations. I thus decided to perform a controlled comparison between a small group of patients we defined as cured and a control group. We used, in addition to the self-rating PWB, a scale that involves a semistructured research interview, the Clinical Interview for Depression (CID) [2]. It offers a very accurate exploration of depressive and anxiety symptoms and is probably the best instrument that is available. It has not been used as much as it should be in research because it takes more time than other scales. A third instrument that we employed was a very brief self-rating questionnaire developed by Robert Kellner, the Symptom Questionnaire (SQ) [3]. It covers both distress and well-being. The well-being scales reflect psychological states (relaxation, contentment, physical well-being, and friendliness), which are quite different from the dimensions of PWB. We found these assessment methods very helpful in other studies we performed. Remitted patients displayed significantly more symptoms than healthy controls, as expected. But they also showed significant impairments in all areas of psychological well-being covered by the PWB [4]. I realized that these patients were better, but not well.
Gratified by the degree of improvement that I had observed in these patients, I forgot that there were still problems. This situation was ideal for testing my psychotherapeutic strategy. I formulated a treatment protocol that was in part based on my experience with Tom, where the articulation of each session was specified, and called it ‘Well-Being Therapy (WBT)’ [5]. We had developed a certain experience with cognitive behavior treatment (CBT) of residual symptoms of depression, which was found to be more effective than a control condition [6], and I thought that comparing the two strategies (CBT and WBT) could be the first step.
Twenty patients with affective disorders [major depression, panic disorder with agoraphobia, social phobia, generalized anxiety disorder (GAD), obsessive-compulsive disorder] who had been successfully treated by behavioral (anxiety disorders) or pharmacological (mood disorders) methods were randomly assigned to either WBT or CBT for residual symptoms [7]. Both WBT and CBT were associated with a significant reduction of residual symptoms as measured by the CID [2] and in PWB well-being [1]. However, when residual symptoms of the two groups were compared after treatment, a significant advantage of WBT over CBT was observed with the CID. WBT was also associated with a significant increase in PWB well-being, particularly in the personal growth scale. The small number of subjects suggested caution in interpreting this difference and the need for further studies with larger samples of patients with specific mood or anxiety disorders.
These preliminary results pointed to the feasibility of WBT in the residual stage of these disturbances. The improvement in residual symptoms may be explained on the basis of the balance between positive and negative affect [7]. If treatment of psychiatric symptoms induces improvement of well-being - and indeed subscales describing well-being are more sensitive to drug effects than subscales describing symptoms [3] - it is conceivable that changes in well-being may affect the balance of positive and negative affect. In this sense, the higher degree of symptomatic improvement that was observed with WBT in this study is not surprising: in the acute phase of affective illness, removal of symptoms may yield the most substantial changes, but the reverse may be true in its residual phase.
The Big Challenge
As other investigators in the field of depression, I was particularly concerned about the high risk of relapse [