Chapter 28
Clinical Applications of Well-Being Therapy

CHIARA RUINI AND GIOVANNI A. FAVA

The concept of psychological well-being has received increasing attention in clinical psychology. Recent investigations have documented the complex relationship between well-being, distress, and personality traits, both in clinical (Fava, Rafanelli, et al., 2001) and nonclinical populations (Ruini et al., 2003). The findings show that psychological well-being could not be equated with the absence of symptomatology, nor with personality traits. It is thus particularly important to analyze the concept of well-being in clinical settings with emphasis on changes in well-being occurring during psychotherapy.

A relevant methodological issue is the broad definition of psychological well-being and optimal functioning. A review by Ryan and Deci (2001) has shown that research on well-being has followed two main directions: (1) happiness and hedonic well-being and (2) development of human potential (eudaimonic well-being). In the first realm all studies dealing with concepts of subjective well-being (Diener, Suh, Lucas, & Smith, 1999), life satisfaction (Neugarten, Havighurst, & Tobin, 1961), and positive emotions (Fredrickson, 2002) can be included. The concept of well-being here is equated with a cognitive process of evaluation of an individual's life, or with the experience of positive emotions.

According to the eudaimonic perspective, happiness consists of fulfilling one's potential in a process of self-realization. Under this umbrella some researchers describe concepts such as the fully functioning person, meaningfulness, self-actualization, and vitality. In particular, Ryff's (1989) model of psychological well-being—encompassing autonomy, personal growth, environmental mastery, purpose in life, positive relations, and self-acceptance—has been found to be particularly useful in clinical psychology and psychotherapy (Fava, Rafanelli, et al., 2001; Rafanelli et al., 2000; Rafanelli et al., 2002; Ruini et al., 2002; Ryff & Singer, 1996). Importantly, in describing optimal human functioning, Ryff and Singer (2008) emphasize Aristotle's admonishment to seek “that which is intermediate,” avoiding excess and extremes. The pursuit of well-being may in fact be so solipsistic and individualistic to leave no room for human connection and the social good; or it could be so focused on responsibilities and duties outside the self that personal talents and capacities are neither recognized or developed (Ryff & Singer, 2008).

These two approaches have led to different areas of research, but they complement each other in defining the construct of well-being (Ryan & Deci, 2001). Some authors have also suggested that they can compensate each other; thus individuals may have profiles of high eudaimonic well-being and low hedonic well-being, or vice versa. These profiles are also associated with sociodemographic variables, such as age, years of education, and employment (Keyes, Shmotkin, & Ryff, 2002). However, in this investigation, the authors underlined the fact that only a small proportion of individuals present with optimal well-being, that is, high hedonic and eudemonic well-being, paving the way for possible psychosocial interventions.

In clinical settings, however, early contributions to well-being research were formulated by authors such as Maslow (1968), Rogers (1961), Allport (1961), and Jung (1933), describing concepts such as self-actualization, fully functioning, maturity, and individuation. In 1958 Jahoda outlined positive criteria for defining mental health, but all these aspects of psychological well-being were neglected for a long time because the development of psychotherapeutic strategies that led to symptom reduction was the main focus of research. Such developments have been particularly impressive for cognitive behavioral therapies (CBTs; Fava, 2000). Even though Parloff, Kelman, and Frank suggested as early as 1954 that the goals of psychotherapy were increased personal comfort and effectiveness, these latter achievements were viewed only as by-products of the reduction of symptoms or as a luxury that clinical investigators could not afford. Four converging developments have modified this stance.

  1. Relapse and recurrence in mood and anxiety disorders.

    There has been increasing awareness of the bleak long-term outcome of mood and anxiety disorders (Fava, 1996; Fava, Tomba, & Grandi, 2007), and particularly in unipolar major depression (Fava, 1999a). Various follow-up studies, in fact, have documented relapses and recurrence in affective disorders (Ramana et al., 1995). As a result, the challenge of treatment of depression today appears to be the prevention of relapse more than the attainment of recovery. Thunedborg, Black, and Bech (1995) found that quality of life measurement, and not symptomatic ratings, could predict recurrence of depression. An increase in psychological well-being may thus protect against relapse and recurrence (Fava, 1999b; Wood & Joseph, 2010). Therefore, an intervention that targets the positive may address an aspect of functioning and health that is typically left unaddressed in conventional treatments.

  2. Clinical response mistaken as recovery.

    There is increasing awareness that clinicians and researchers in clinical psychiatry confound response to treatment with full recovery (Fava, 1996). A substantial residual symptomatology (anxiety, irritability, interpersonal problems) was found to characterize the majority of patients who were judged to be remitted according to Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria and no longer in need of active treatment. Further, psychological well-being needs to be incorporated in the definition of recovery (Fava, 1996). Ryff and Singer (1996) have suggested that the absence of well-being creates conditions of vulnerability to possible future adversities and that the route to enduring recovery lies not exclusively in alleviating the negative, but in engendering the positive. Interventions that bring the person out of the negative functioning (e.g., exposure treatment in panic disorder with agoraphobia) are one form of success, but facilitating progression toward the restoration of positive is quite another (Ryff & Singer, 1996).

  3. Quality of life and positive health.

    There has been an upsurge of interest in quality of life assessment in health care (Fava & Sonino, 2010; Frisch, 2006) and in the concept of positive health (Ryff & Singer, 2000). Clinical researchers have turned their attention to quality-of-life assessment as a means of broadening the evaluation of treatment outcome encompassing satisfaction, functioning, and objective life circumstances (Gladis, Gosch, Dishuk, & Crits-Cristoph, 1999). The benefits of well-being are now well documented in cross-sectional and longitudinal research and include a better physical health (Chida & Steptoe, 2008; Fava & Sonino, 2010; Howell, Kern, & Lyubomirsky, 2007), improved productivity at work, having more meaningful relationships, and social functioning (Seeman, Singer, Ryff, Dienberg Love, & Levy-Storms, 2002). In the same line, research has indeed suggested the important role of positive affectivity (Fredrickson & Joiner, 2002) in promoting resilience and growth. Such directions in health care call for strategies to enhance the well-being that underlies these constructs.

  4. The growth of positive psychology.

    Issues such as the building of human strength in different psychotherapeutic strategies and the characteristics of subjective well-being have become increasingly important in psychological research (Diener et al., 1999; Gillham & Seligman, 1999). A growing number of investigations on positive emotions (Fredrickson & Joiner, 2002), subjective well-being (Diener, 2000; Diener et al., 1999), human strengths (Park, Peterson, & Seligman, 2004), and other positive personality characteristics such as compassion, hope, and altruism (Park et al., 2004) paved the way for developing “positive interventions” (Magayar-Moe, 2009; Seligman, Steen, Park, & Peterson, 2005; Sin & Lyubomirsky, 2009) such as the positive psychotherapy (Seligman, Rashid, & Parks, 2006); wisdom psychotherapy (Linden, Baumann, Lieberei, Lorenz, & Rotter, 2011); gratitude interventions (Wood, Maltby, Gillett, Linley, & Joseph, 2008); positive coaching (Biswas-Diener, 2010); strengths-based approaches (Biswas-Diener, Kashdan, & Minhas, 2011; Govindji & Linley, 2007; Linley & Burns, 2010); hope therapy (Geraghty, Wood, & Hyland, 2010; Snyder, Ilardi, Michael, Yamhure, & Sympson, 2000); and forgiveness therapy (Lamb, 2005).

In a recent meta-analysis, Bolier et al. (2013) showed that these positive psychology interventions significantly enhance subjective and psychological well-being and reduce depressive symptoms, even though effect sizes were in the small to moderate range. The main aim of all these positive interventions, in fact, is the promotion of happiness, positive emotions, and positivity in general. However, excessively elevated levels of positive emotions can become detrimental and are more connected with mental disorders and impaired functioning (Fredrickson & Losada, 2005). The issues of positivity and well-being, thus, need to be approached considering the complexity of phenomena in clinical settings, and the balance between positivity and distress (Rafanelli et al., 2000; Ruini & Fava, 2012).

The Complexity of Well-Being in Clinical Settings

Early pioneer works to enhance well-being include Ellis and Becker's (1982) guide to personal happiness, Fordyce's (1983) program to increase happiness, Padesky's (1994) work on schema change processes, Frisch's (2006) quality of life therapy, and Horowitz and Kaltreider's (1979) work on positive states of mind. However, these approaches had only a limited effect in clinical practice.

In a naive conceptualization, yet the one implicitly endorsed by DSM, well-being and distress are seen as mutually exclusive (i.e., well-being is lack of distress). According to this model, well-being should result from removal of distress. Yet, there is evidence both in psychiatric (Rafanelli et al., 2000) and psychosomatic (Fava, Mangelli, & Ruini, 2001) research to question such views. In order to justify therapeutic efforts aimed at increasing psychological well-being, we should demonstrate impaired levels of psychological well-being in a clinical population. This was achieved by using an instrument, the Psychological Well-Being Scales (PWB) developed by Ryff (1989). In a controlled investigation (Rafanelli et al., 2000), 20 remitted patients with mood or anxiety disorders displayed significantly lower levels in all six dimensions of well-being according to the PWB compared to healthy control subjects matched for sociodemographic variables. It is obvious, however, that the quality and degree of impairment may vary from patient to patient and within the same patient, according to clinical status. Further, Fava, Ranfanelli, et al. (2001) administered the PWB to 30 remitted patients with panic disorder and 30 matched controls and found impairments in some specific areas, but not in others. The model described by Ryff (1989) and Ryff and Keyes (1995) was thus found to satisfactorily describe the variations in psychological well-being that may occur in a clinical setting.

In 1991 Garamoni et al. suggested that healthy functioning is characterized by an optimal balance of positive and negative cognitions and affects, and that psychopathology is marked by deviations from the optimal balance. More recently, Larsen and Prizmic (2008) argued that the balance of positive to negative affect (i.e., the positivity ratio) is a key factor in well-being and in defining whether a person flourishes. Several authors (Fredrickson & Losada, 2005; Larsen & Prizmic, 2008; Schwartz, 1997; Schwartz et al., 2002) suggest that, to maintain an optimal level of emotional well-being and positive mental health, individuals need to experience approximately three times more positive than negative affect. Fredrickson and Losada (2005), in fact, have found that above this ratio, there is an excessively high positivity that becomes detrimental to functioning. Grant and Schwartz (2011) suggest that all positive traits, states, and experiences have costs that, at high levels, may begin to outweigh their benefits, creating the non-monotonicity of an inverted U. For this reason, traditional clinical psychology has a crucial role in planning and implementing interventions for enhancing positive affect. Positive interventions, thus, should not be simply aimed to increase happiness and well-being, but should consider the complex balance between psychological well-being and distress (MacLeod & Moore, 2000) and be targeted to specific and individualized needs.

These clinical and conceptual frameworks were thus instrumental in developing a well-being enhancing psychotherapeutic strategy, defined as well-being therapy (Fava, 1999b; Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998; Fava & Ruini, 2003; Ruini & Fava, 2012).

Protocol of Well-Being Therapy

Well-being therapy is a short-term psychotherapeutic strategy that extends over eight sessions, which may take place every week or every other week. The duration of each session may range from 30 to 50 minutes. It is a technique that emphasizes self-observation (Emmelkamp, 1974), with the use of a structured diary, and interaction between patients and therapists. Well-being therapy is based on Ryff's cognitive model of psychological well-being (Ryff, 1989). This model was selected on the basis of its easy applicability to clinical populations (Fava, Rafanelli, et al., 2001; Rafanelli et al., 2000). Well-being therapy is structured, directive, problem-oriented, and based on an educational model. The development of sessions is described in the following sections.

Initial Sessions

These sessions are simply concerned with identifying episodes of well-being and setting them into a situational context, no matter how short-lived they were. Patients are asked to report in a structured diary the circumstances surrounding their episodes of well-being, rated on a 0 to 100 scale, with 0 being absence of well-being and 100 the most intense well-being that could be experienced. When patients are assigned this homework, they often object that they will bring a blank diary, because they never feel well. It is helpful to reply that these moments do exist but tend to pass unnoticed. Patients should therefore monitor them anyway.

Meehl (1975) described

how people with low hedonic capacity should pay greater attention to the “hedonic book keeping” of their activities than would be necessary for people located midway or high on the hedonic capacity continuum. That is, it matters more to someone cursed with an inborn hedonic defect whether he is efficient and sagacious in selecting friends, jobs, cities, tasks, hobbies, and activities in general. (p. 305)

Patients are particularly encouraged to search for well-being moments, not only in special hedonic-stimulating situations, but also during their daily activities. Several studies have shown that individuals preferentially invest their attention and psychic resources in activities associated with rewarding and challenging states of consciousness, in particular with optimal experience (Csikszentmihalyi, 1990; Delle Fave & Massimini, 2003). Patients are thus asked to report when they feel optimal experiences in their daily life and are invited to list the associated activities or situations.

This initial phase generally extends over a couple of sessions. Yet its duration depends on the factors that affect any homework assignment, such as resistance and compliance.

Intermediate Sessions

Once the instances of well-being are properly recognized, the patient is encouraged to identify thoughts and beliefs leading to premature interruption of well-being. The similarities with the search for irrational, tension-evoking thoughts in Ellis and Becker's rational-emotive therapy (1982) and automatic thoughts in cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) are obvious. The trigger for self-observation is, however, different, being based on well-being instead of distress.

This phase is crucial, since it allows the therapist to identify which areas of psychological well-being are unaffected by irrational or automatic thoughts and which are saturated with them. The therapist may challenge these thoughts with appropriate questions, such as “What is the evidence for or against this idea?” or “Are you thinking in all-or-none terms?” (Beck et al., 1979). The therapist may also reinforce and encourage activities that are likely to elicit well-being (for instance, assigning the task of undertaking particular pleasurable activities for a certain time each day). Such reinforcement may also result in graded task assignments (Beck et al., 1979), with special reference to exposure to feared or challenging situations, which the patient is likely to avoid. Over time patients may develop ambivalent attitudes toward well-being. They complain of having lost it, or they long for it, but at the same time they are scared when positive moments actually happen in their lives. These moments trigger specific negative automatic thoughts, usually concerning the fact that they will not last (i.e., it's too good to be true) or that they are not deserved by patients, or that they are attainable only by overcoming difficulties and distress. Encouraging patients in searching and engaging in optimal experiences and pleasant activities is therefore crucial at this stage of well-being therapy (WBT).

This intermediate phase may extend over two or three sessions, depending on the patient's motivation and ability, and it paves the way for the specific well-being enhancing strategies.

Final Sessions

The monitoring of the course of episodes of well-being allows the therapist to realize specific impairments in well-being dimensions according to Ryff's conceptual framework. An additional source of information may be provided by Ryff's PWB, an 84-item self-rating inventory (Ryff, 1989). In the original validation study of well-being therapy (Fava, Rafanelli, Cazzaro, et al., 1998), however, PWB results were not available to the therapist, who just worked from the patient's diary. Ryff's six dimensions of psychological well-being are progressively introduced to the patients, as long as the material that is recorded lends itself to it. For example, the therapist could explain that autonomy consists of possessing an internal locus of control, independence, and self-determination; or that personal growth consists of being open to new experiences and considering self as expanding over time, if the patient's attitudes show impairments in these specific areas. Errors in thinking and alternative interpretations are then discussed. At this point in time the patient is expected to be able to readily identify moments of well-being, be aware of interruptions to well-being feelings (cognitions), utilize cognitive behavioral techniques to address these interruptions, and pursue optimal experiences. Meeting the challenge that optimal experiences may entail is emphasized, because it is through this challenge that growth and improvement of self can take place.

Conceptual Framework of Well-Being Therapy

Cognitive restructuring in WBT follows Ryff's conceptual framework (Ryff & Singer, 1996). The goal of the therapist is to lead the patient from an impaired level to an optimal level in the six dimensions of psychological well-being. This means that patients are not simply encouraged to pursue the highest possible levels in psychological well-being, in all dimensions, but to obtain a balanced functioning. This optimal-balanced well-being could be different from patient to patient, according to factors such as personality traits, social roles, and cultural and social contexts (Ruini & Fava, 2012; Ruini et al., 2003)

The various dimensions of positive functioning can compensate each other (some being more interpersonally oriented, some more personal/cognitive), and the aim of WBT, such as other positive interventions, should be the promotion of an optimal-balanced functioning between these dimensions, in order to facilitate individual flourishing (Keyes, 2002). This means that sometimes patients should be encouraged to decrease their level of positive functioning in certain domains. Without this clinical framework, the risk is to lead patients to having too high levels of self-confidence, with unrealistic expectations that may become dysfunctional and/or stressful to individuals (see Table 28.1).

Table 28.1 Modifications of Well-Being Following WBT

Ryff Psychological Well-Being Dimensions and Related Dimensions Low Level Balanced-Functional Level High Level
Environmental mastery, Wisdom, Self-determination, Optimal experience, Passion The person has or feels difficulties in managing everyday affairs; feels unable to change or improve surrounding context; is unaware of surrounding opportunities; lacks sense of control over external world. The person has a sense of mastery and competence in managing the environment; controls external activities; makes effective use of surrounding opportunities; able to create or choose contexts suitable to personal needs and values. The person is unable to savor positive emotions and hedonic pleasure. He or she is unable to relax and gets easily bored.
Personal growth, Meaning, Post-traumatic growth, Benefit finding, Intrinsic motivation The person has a sense of personal stagnation; lacks sense of improvement or expansion over time; feels bored and uninterested with life; feels unable to develop new attitudes or behaviors. The person has a feeling of continued development; sees self as growing and expanding; is open to new experiences; has sense of realizing own potential; sees improvement in self and behavior over time. The person is unable to process negativity; forgets or does not give enough emphasis to past negative experiences; cultivates benign illusions that do not fit with reality; sets unrealistic standards for overcoming adversities
Purpose in life, Goals, Hope, Passion The person lacks a sense of meaning in life; has few goals or aims, lacks sense of direction, does not see purpose in past life; has no outlooks or beliefs that give life meaning. The person has goals in life and a sense of directedness; feels there is meaning to present and past life; holds beliefs that give life purpose; has aims and objectives for living, despite adversities. The person has obsessional passions and is unable to admit failures. He or she manifests persistence and rigidity and is unable to change perspective and goals. Excessive hope is paralyzing and hampers facing negativity and failures.
Autonomy, Leadership, Locus of controls, Self-determination, Bravery The person is overconcerned with the expectations and evaluation of others; relies on judgment of others to make important decisions; conforms to social pressures to think or act in certain ways. The person is self-determining and independent; able to resist to social pressures; regulates behavior from within; evaluates self by personal standards. The person is unable to get along with other people, to work in team, to learn from others. He or she spends time and energy for fighting for his or her opinions and rights
This person relies only on himself or herself for solving problems, and is unable to ask for advice or help.

Environmental Mastery

This is the most frequent impairment that emerges, which is felt by patients as a lack of sense of control. This leads the patients to miss surrounding opportunities, with the possibility of subsequent regret over them. On the other hand, sometimes patients may require help because they are unable to enjoy and savor daily life, as they are too engaged in work or family activities. Their ability to plan and solve problems may lead others to constantly ask for their help, with the resulting feeling of being exploited and overwhelmed by requests. These extremely high levels of environmental mastery thus become a source of stress and allostatic load to the individual. Environmental mastery can be considered a key mediator or moderator of stressful life experiences (Fava, Guidi, Semprini, Tomba, & Sonino, 2010). A positive characterization of protective factors converges with efforts to portray the individual as a psychological activist, capable of proactive and effective problem solving, rather than passively buffeted by external forces (Ryff & Singer, 1998), but also capable of finding time for rest and relaxing in daily life.

Personal Growth

Patients often tend to emphasize their distance from expected goals much more than the progress that has been made toward goal achievement. A basic impairment that emerges is the inability to identify the similarities between events and situations that were handled successfully in the past and those that are about to come (transfer of experiences). On the other hand, people with levels of personal growth that are too high tend to forget or do not give enough emphasis to past experiences because they are exclusively future oriented. Negative or traumatic experiences could particularly be underestimated, as a sort of extreme defense mechanism (denial), that is, “I just need to get over this situation and go on with my life” (Held, 2002; Norem & Chang, 2002). Dysfunctional high personal growth is similar to a cognitive benign illusion, or wishful thinking, which hinders the integration of past (negative) experiences and their related learning process.

Purpose in Life

Patients may perceive a lack of sense of direction and may devalue their function in life. This particularly occurs when environmental mastery and sense of personal growth are impaired. On the other hand, many other conditions worthy of clinical attention may arise from too high levels of purpose in life. First of all, individuals with a strong determination in realizing one (or more) life goal(s) could dedicate themselves fully to their activity, thereby allowing them to persist, even in the face of obstacles, and to eventually reach excellence. This again could have a cost in terms of stress. Further, Vallerand et al. (2003) have proposed the concept of obsessive passion for describing an activity or goal that becomes a central feature of one's identity and serves to define the person. Individuals with an obsessive passion come to develop ego-invested self-structures (Hodgins & Knee, 2002) and, eventually, display a rigid persistence toward the activity, thereby leading to less than optimal functioning. Such persistence is rigid because it not only occurs in the absence of positive emotions and sometimes of positive feedbacks, but even in the face of important personal costs such as damaged relationships, failed commitments, and conflicts with other activities in the person's life (Vallerand et al., 2007). The individual engagement for a certain goal could thus become a form of psychological inflexibility (Kashdan & Rottenberg, 2010) that is more connected with psychopathology than well-being. Some individuals, in fact, remains attached to their goals even when these seem to be unattainable, and keep believing that they would be happy pending the achievement of these goals. These mechanisms are associated with hopelessness (Hadley & MacLeod, 2010; MacLeod & Conway, 2007) and parasuicidal behaviors (Vincent, Boddana, & MacLeod, 2004). Further, this confirms the idea that hope, another future-oriented positive emotion, can become paralyzing and hampers facing and accepting negativity and failures (Bohart, 2002; Geraghty et al., 2010).

Autonomy

It is a frequent clinical observation that patients may exhibit a pattern whereby a perceived lack of self-worth leads to unassertive behavior. For instance, patients may hide their opinions or preferences, go along with a situation that is not in their best interests, or consistently put their needs behind the needs of others. This pattern undermines environmental mastery and purpose in life and these, in turn, may affect autonomy, since these dimensions are highly correlated in clinical populations. Such attitudes may not be obvious to the patients, who hide their considerable need for social approval. A patient who tries to please everyone is likely to fail to achieve this goal and the unavoidable conflicts may result in chronic dissatisfaction and frustration. On the other hand, in Western countries particularly, individuals are culturally encouraged to be autonomous and independent. Certain individuals develop the idea that they should rely only on themselves for solving problems and difficulties, and are thus unable to ask for advice or help. Also in this case, an unbalanced high autonomy can become detrimental for social/interpersonal functioning (Seeman et al., 2002). Some patients complain they are not able to get along with other people, or work in teams, or maintain intimate relationships, because they are constantly fighting for their opinions and independence.

Self-Acceptance

Patients may maintain unrealistically high standards and expectations, driven by perfectionistic attitudes (that reflect lack of self-acceptance) and/or endorsement of external instead of personal standards (that reflect lack of autonomy). As a result, any instance of well-being is neutralized by a chronic dissatisfaction with oneself. A person may set unrealistic standards for her performance. On the other hand, an inflated self-esteem may be a source of distress and clash with reality, as was found to be the case in cyclothymia and bipolar disorder (Fava, Rafanelli, Tomba, Guidi, & Grandi, 2011; Garland et al., 2010).

Positive Relations With Others

Interpersonal relationships may be influenced by strongly held attitudes of perfectionism that the patient may be unaware of and that may be dysfunctional. Impairments in self-acceptance (with the resulting belief of being rejectable and unlovable, or others being inferior and unlovable) may also undermine positive relations with others. There is a large body of literature (Uchino, Cacioppo, & Kiecolt-Glaser, 1996) on the buffering effects of social integration, social network properties, and perceived support. On the other hand, little research has been done on the possible negative consequences of an exaggerated social functioning. Characteristics such as empathy, altruism, and generosity are usually considered universally positive. However, in clinical practice, patients often report a sense of guilt for not being able to help someone, or to forgive an offense. An individual with a strong pro-social attitude can sacrifice his or her needs and well-being for those of others, and this in the long run becomes detrimental and sometimes disappointing. This individual can also become overconcerned and overwhelmed by others' problems and distress and be at risk for burn-out syndrome. Finally, a generalized tendency to forgive others and be grateful toward benefactors could mask low self-esteem and low sense of personal worth.

Validation Studies

Well-being therapy has been employed in several clinical studies. Other studies are currently in progress.

Residual Phase of Affective Disorders

The effectiveness of well-being therapy in the residual phase of affective disorders was first tested in a small controlled investigation (Fava, Rafanelli, Cazzaro, et al., 1998). Twenty patients with affective disorders who had been successfully treated by behavioral (anxiety disorders) or pharmacological (mood disorders) methods were randomly assigned to either a WBT or CBT of residual symptoms. Both well-being and cognitive behavioral therapies were associated with a significant reduction of residual symptoms, as measured by the Clinical Interview for Depression (CID; Guidi, Fava, Bech, & Paykel, 2011; Paykel, 1985), and in PWB well-being. However, when the residual symptoms of the two groups were compared after treatment, a significant advantage of well-being therapy over cognitive behavioral strategies was observed with the CID. Well-being therapy was associated also with a significant increase in PWB well-being, particularly in the Personal Growth scale.

The improvement in residual symptoms was explained on the basis of the balance between positive and negative affect (Fava, Rafanelli, Cazzaro, et al., 1998). 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 (Kellner, 1987; Rafanelli & Ruini, 2012), 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 well-being therapy 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.

Prevention of Recurrent Depression

Well-being therapy was a specific and innovative part of a cognitive behavioral package that was applied to recurrent depression (Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998). This package included also CBT of residual symptoms and lifestyle modification. Forty patients with recurrent major depression, who had been successfully treated with antidepressant drugs, were randomly assigned to either this cognitive behavioral package including well-being therapy or clinical management. In both groups, antidepressant drugs were tapered and discontinued. The group that received CBT-WBT had a significantly lower level of residual symptoms after drug discontinuation in comparison with the clinical management group. CBT-WBT also resulted in a significantly lower relapse rate (25%) at a 2-year follow-up than did clinical management (80%). At a 6-year follow-up (Fava et al., 2004) the relapse rate was 40% in the former group and 90% in the latter. Further, the group treated with CBT-WBT had a significantly lower number of recurrences when multiple relapses were taken into account (Fava et al., 2004).

These promising results have been recently replicated by a group of German investigators (Stangier et al., 2013) who applied WBT together with CBT and mindfulness as a maintenance therapy for patients with recurrent depression. One hundred and eighty patients with three or more previous major depressive episodes were randomly assigned to 16 sessions of either CBT or manualized psychoeducation over 8 months and then followed up for 12 months. Even though time to relapse or recurrence of major depression did not differ significantly between treatment conditions, a significant interaction was observed between treatment condition and number of previous episodes (five or more). Within the subsample of patients with five or more previous episodes, CBT was significantly superior to manualized psychoeducation.

Loss of Clinical Effect During Drug Treatment

The return of depressive symptoms during maintenance antidepressant treatment is a common and vexing clinical phenomenon (Fava & Offidani, 2011). Ten patients with recurrent depression who relapsed while taking antidepressant drugs were randomly assigned to dose increase or to a sequential combination of cognitive-behavior and well-being therapy (Fava, Ruini, Rafanelli, & Grandi, 2002). Four out of five patients responded to a larger dose, but all relapsed again on that dose by 1 year follow-up. Four out of the 5 patients responded to psychotherapy and only one relapsed. The data suggest that application of well-being therapy may counteract loss of clinical effect during long-term antidepressant treatment.

Treatment of Generalized Anxiety Disorder

Well-being therapy has been applied for the treatment of generalized anxiety disorder (GAD; Fava et al., 2005; Ruini & Fava, 2009). Twenty patients with DSM-IV GAD were randomly assigned to eight sessions of CBT or the sequential administration of four sessions of CBT followed by four other sessions of WBT. Both treatments were associated with a significant reduction of anxiety. However, significant advantages of the WBT-CBT sequential combination over CBT were observed, both in terms of symptom reduction and psychological well-being improvement. These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. A possible explanation for these findings is that self-monitoring of episodes of well-being may lead to a more comprehensive identification of automatic thoughts than that entailed by the customary monitoring of episodes of distress in cognitive therapy (Ruini & Fava, 2009).

Cyclothymic Disorder

Well-being therapy was recently applied (Fava et al., 2011) in sequential combination with CBT for the treatment of cyclothymic disorder, which involves mild or moderate fluctuations of mood, thought, and behavior without meeting formal diagnostic criteria for either major depressive disorder or mania (Baldessarini, Vázquez, & Tondo, 2011). Sixty-two patients with DSM-IV cyclothymic disorder were randomly assigned to CBT-WBT (n = 31) or clinical management (CM; n = 31). An independent blind evaluator assessed the patients before treatment, after therapy, and at 1- and 2-year follow-ups. At post-treatment, significant differences were found in all outcome measures, with greater improvements after treatment in the CBT-WBT group compared to the CM group. Therapeutic gains were maintained at 1- and 2-year follow-ups. The results of this investigation suggest that a sequential combination of CBT and WBT, which addresses both polarities of mood swings and comorbid anxiety, was found to yield significant and persistent benefits in cyclothymic disorder.

Posttraumatic Stress Disorder

The use of WBT for the treatment of traumatized patients has not been tested in controlled investigations yet. However, two cases were reported (Belaise, Fava, & Marks, 2005) in which patients improved with WBT, even though their central trauma was discussed only in the initial history-taking session. The findings from these two cases should of course be interpreted with caution (the patients may have remitted spontaneously), but they are of interest because they indicate an alternative route to overcoming trauma and developing resilience and warrant further investigation (Fava & Tomba, 2009).

Child Well-Being Therapy

Well-being therapy has been recently modified to be applied with children and adolescents, both in clinical and educative settings. In clinical setting, it was applied to a child population of patients with mood, anxiety, and conduct disorders, with the aim of testing its effects in reducing symptoms and in improving new skills and competencies in children (Albieri, Visani, Offidani, Ottolini, & Ruini, 2009). Four children with different diagnoses according to DSM-IV criteria (one oppositional-defiant disorder; one attention-deficit/hyperactivity disorder [ADHD]; one major depressive disorder; and one GAD) underwent this new treatment protocol. None of these children were receiving pharmacological treatment, but two of them had a special tutor for helping them in school activities. WBT intervention consisted of eight 1-hour sessions, once a week, and was conducted using games and role-playing. It involved the use of a diary during each session with specific homework assignments. Positive and negative emotions were discussed with patients from the beginning of the protocol, but in the first four sessions more emphasis was upon negative emotions, whereas in the last three sessions the focus was upon the enhancement of psychological well-being according to a sequential strategy. Two additional sessions were addressed to parents' training. Child WBT was associated in all patients with a decrease in symptomatology (particularly anxiety and somatization) and an improvement in psychological well-being (particularly autonomy and interpersonal functioning). In two of our four patients, WBT was associated also with improvements in school performance.

The innovative ingredient of child WBT is the focus on promoting psychological well-being and optimal functioning in children (Caffo, Belaise, & Forresi, 2008). Further, WBT strategies were feasible for different sets of symptoms (anxious, depressive, behavioral). These results are promising, but further research with controlled design is needed.

In school settings, the protocol of WBT was modified for a group setting and for students aged 11 to 18. In three controlled investigations (Ruini, Belaise, Brombin, Caffo, & Fava, 2006; Ruini et al., 2009; Tomba et al., 2010) school WBT was compared to CBT school protocol or placebo and resulted to be associated with a decrease in anxiety and somatization, and an increase in psychological well-being. School-based WBT could have important clinical implications in view of the documented high prevalence of somatic symptoms in children and adolescents (Ginsburg, Riddle, & Davies, 2006; Muris, Vermeer, & Horselenberg, 2008). With young populations, promoting positive functioning and building individual strengths could also be more beneficial in the long term than simply addressing depressive or anxious symptoms.

Potential Mechanisms of Action and Case Studies

Well-being therapy's effectiveness may be based on two distinct yet ostensibly related clinical phenomena. The first has to do with the fact that an increase in psychological well-being may have a protective effect in terms of vulnerability to chronic and acute life stresses (Ryff & Singer, 1998, 2000). The second has to do with the complex balance of positive and negative affects. There is extensive research—reviewed in detail elsewhere (Rafanelli et al., 2000; Ruini et al., 2003)—that indicates a certain degree of inverse correlation between positive and negative affects. As a result, changes in well-being may induce a decrease in distress, and vice versa. In the acute phase of illness, removal of symptoms may yield the most substantial changes, but the reverse may be true in its residual phase. An increase in psychological well-being may decrease residual symptoms that direct strategies (whether cognitive behavioral or pharmacological) would be unlikely to affect.

Further, it has been suggested that cognitive behavioral psychotherapy may work at the molecular level to alter stress-related gene expression and protein synthesis or influence mechanisms implicated in learning and memory acquisition in neuronal structures (Goddard & Charney, 1997). For instance, in one study sadness and happiness affected different brain regions: Sadness activated limbic and paralimbic structures, whereas happiness was associated with temporal parietal decreases in cortical activity (George et al., 1995). Such effects were not merely opposite activity in identical brain regions. The pathophysiological substrates of well-being therapy may thus be different compared to symptom-oriented cognitive behavioral strategies, to the same extent that well-being and distress are not merely opposites (Rafanelli et al., 2000).

By a psychotherapeutic viewpoint, the techniques that are used in WBT derived from traditional CBT packaging—which may also involve positive thinking (MacLeod & Moore, 2000)—may include cognitive restructuring (modification of automatic or irrational thoughts), scheduling of activities (mastery, pleasure, and graded task assignments), assertiveness training, and problem solving (Beck et al., 1979; Ellis & Becker, 1982; Pava, Fava, & Levenson, 1994; Weissman & Markowitz, 1994). What differentiates well-being therapy from standard cognitive therapies is the focus (which in well-being therapy is on instances of emotional well-being, whereas in cognitive therapy it is on psychological distress). A second important distinction is that in cognitive therapy the goal is abatement of distress through automatic thought control or contrast, whereas in well-being therapy the goal is promotion of optimal functioning, along Ryff's (1989) dimensions, as illustrated by the following two clinical cases. The first one provides an example of how obsessions and negative thoughts are triggered by initial instances of well-being. The second one provides an example of cognitive restructuring performed according to well-being concepts and how this yielded to behavioral modifications.

Case Study A

Tom is a 23-year-old philosophy student with a severe obsessive illness, fulfilling the DSM-IV criteria, and refractory to drug treatment (fluvoxamine up to 200 mg per day and clomipramine 150 mg per day) and cognitive behavioral therapy (he dropped out of treatment after six sessions). He is treated by the second author with well-being therapy. After the first two sessions he is able to identify that obsessions start when well-being ensues. Adding an observer's interpretation column makes the patient realize that an effective contrast of pre-obsessive thoughts triggered by well-being may prevent obsessions and ruminations (Table 28.2). As long as therapy goes on (one session every other week), the intensity and perceived importance of obsessions decrease. After eight sessions, the patient no longer meets DSM-IV criteria for obsessive-compulsive disorder and feels much better. He is able to finish his studies. He no longer reports obsessive-compulsive disturbances at a 4-year follow-up.

Table 28.2 Prevention of Obsessive Thoughts by Cognitive Restructuring

Situation Feeling of Well-Being Interrupting Thoughts Observer's Interpretation
Lunch with family Maybe I am getting better and my life will change. A terrible crisis is on its way. I feel it… To acknowledge some progress does not mean asking for trouble. The problem is that you do not believe you can feel well. You are afraid of being well, because you do not think it is possible.

Case Study B

A middle-aged male patient with recurrent major depression (third episode) may learn how his lack of autonomy leads his workmates to consistently take advantage of him. This situation results in a work load that, because of its diverse nature, undermines his environmental mastery and constitutes a significant stress, also in terms of working hours. The situation is accepted in virtue of a low degree of self-acceptance: The patient claims that this is the way he is, but at the same time he is dissatisfied with himself and chronically irritable. When he learns to say no to his colleagues (assertive training) and consistently endorses this attitude, a significant degree of distress ensues, linked to perceived disapproval by others. However, as time goes by, his tolerance for self-disapproval gradually increases and in the last session he is able to make the following remark: “Now my workmates say that I am changed and have become a bastard. In a way I am sorry, since I always tried to be helpful and kind to people. But in another way I am happy, because this means that—for the first time in my life—I have been able to protect myself.” The patient had no further relapse at a 6-year follow-up, while being medication free.

This clinical picture illustrates how an initial feeling of well-being (being helpful to others) that was identified in the diary was likely to lead to an overwhelming distress. Its appraisal and the resulting change in behavior initially led to more distress, but then yielded a lasting remission. The example clarifies that a similar behavioral change might have been achieved by distress-oriented psychotherapeutic strategies (indeed, the approach that was used to tackle this specific problem was no different). However, these changes would not have been supported by specific modifications of well-being dimensions.

Conclusion

WBT has been originally developed as a strategy for promoting psychological well-being that was still impaired after standard pharmacological or psychotherapeutic treatments. It was based on the assumption that these impairments may vary from one illness to another, from patient to patient, and even from one episode to another of the same illness in the same patient. These impairments represent a vulnerability factor for adversities and relapses (Fava & Tomba, 2009; Ryff & Singer, 1996; Wood & Joseph, 2010). WBT, thus, can be considered a therapeutic positive intervention developed in clinical psychology, which takes into consideration both well-being and distress in predicting patients' clinical outcomes (Rafanelli & Ruini, 2012). This individualized approach characterizes the treatment protocol, which requires careful self-monitoring before any cognitive restructuring takes place. WBT develops on the basis of findings from self-observation in the diary. In some cases some psychological dimensions need reinforcement and growth. In other cases excessive or distorted levels of certain dimensions need to be adjusted because they may become dysfunctional and impede flourishing.

As a result, WBT may be used to address specific areas of concern in the course of treatment, in sequential combination with other approaches of pharmacological and psychological nature. The model is realistic, instead of idealistic, but more in line with the emerging evidence on the unsatisfactory degree of remission that one course of treatment entails (Fava et al., 2007). Unlike standard cognitive therapy, which is based on rigid specific assumptions (e.g., the cognitive triad in depression), WBT is characterized by flexibility (Kashdan & Rottenberg, 2010) and by an individualized approach for addressing psychological issues that other therapies have left unexplored, such as the promotion of eudaimonic well-being and optimal human functioning.

Summary Points

  • Impairments in well-being are observable in patients successfully treated for anxiety and mood disorders.
  • These impairments create conditions of vulnerabilities to stress and relapses.
  • A specific psychotherapeutic strategy aimed at improving patients' well-being has been created and validated in a number of investigations (well-being therapy, or WBT).
  • WBT has been found to be effective in promoting optimal functioning in patients with mood and anxiety disorders, such as depression, bipolar disorders, generalized anxiety disorder, and posttraumatic stress disorder.
  • A modified version of WBT protocol, adapted for younger population, has been validated in school settings and with children with anxiety and behavioral disorders.
  • WBT provides an individualized approach for addressing psychological issues that other therapies have left unexplored, such as the promotion of eudaimonic well-being and optimal human functioning.

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