severity of the depressive disturbances was not specifically evaluated and the symptomatology was probably mild. Nonetheless, the results were quite impressive.
Understanding the Specificity of Well-Being Therapy
My research group was very pleased with the results obtained with our approach to recurrent depression [11, 14]. In discussing the data with Chiara Rafanelli, who had performed all psychological evaluations blind to the treatment assignments, an important issue came up. What was the specific role of WBT? In our previous study that did not involve WBT [6, 9, 10], the results had been less positive, but this did not necessarily mean that WBT was responsible for them.
Chiara Rafanelli and I thus decided to perform another controlled investigation. The object of our study this time was a very common form of anxiety, GAD. We had come to the conclusion that probably the sequential combination of CBT and WBT was our best bet in an acute disorder, but was this combination going to be better than just performing CBT? Twenty patients with GAD were randomly assigned to 8 sessions of CBT or the sequential administration of CBT followed by another 4 sessions of WBT [19]. Both treatments were associated with a significant reduction of anxiety. However, significant advantages of the CBT/WBT sequential combination over CBT were observed, both in terms of symptom reduction and psychological well-being improvement as measured by CID [2], PWB [1], and SQ [3]. These results suggested the feasibility and clinical advantages of adding WBT to the treatment of GAD. A possible explanation of 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 [20], and therefore may result in more effective cognitive restructuring. These results also lend support to our hypothesis that WBT provides something that CBT alone does not possess.
Addressing Cyclothymic Disorder
Until then we had conceptualized WBT essentially as a tool for increasing psychological well-being in people who had impaired levels. But in my clinical practice I had observed patients in whom these psychological dimensions were exaggerated or unrealistic, whose environmental mastery, for instance, led them to take too many challenges and to be under very stressful situations. Was the role of WBT simply that of a well-being enhancer or could it also serve a stabilizing function?
We thus decided to apply WBT to 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 [21]. It is a common and disabling condition that does not attract much research attention since no drugs have been patented for its treatment. Sixty-two patients with cyclothymic disorder were randomly assigned to the sequential combination of CBT and WBT or clinical management. An independent blind evaluator assessed the patients before treatment, after therapy, and at 1 - and 2-year followups. The CID [2] and the Mania Scale developed by Per Bech and his collaborators [22] were used to evaluate symptoms. After treatment, a significant difference was found in outcome measures, with greater improvements in the CBT/WBT group compared to clinical management. Therapeutic gains were maintained at the 1- and 2-year follow-ups [21]. The results thus indicate that WBT may address both polarities of mood swings and comorbid anxiety, and may yield significant and lasting benefits in cyclothymic disorder.
What Is the Role of Well-Being Therapy?
The studies that are summarized in this chapter and other investigations that are going to be discussed later in this book indicate that WBT's potential role was broader than originally assumed (improving the risk of relapse in the residual phase of mood and anxiety disorders). Developing the protocols for these studies and using WBT in clinical practice paved the way for a refinement of the original formulation of WBT [5]. With the contribution of Elena Tomba, a first modification was offered in 2009 [23]. Further input came when a leading figure of American CBT, Jesse H. Wright, started using WBT [24]. In Part II of this book, I will describe how WBT can actually be implemented in clinical practice. After a chapter on clinical evaluation, the 8-session program will be described. Such a format, when needed, can be extended to 12 or more sessions or abridged to 4 sessions if preceded by CBT.
References
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