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 [6]. I explained to Tom how some thoughts he had reported could fit Beck's model of automatic thought [6]. I then asked him to add another column to his diary (in addition to situation, feeling of well-being, and interrupting thoughts) that was indicated as ‘observer's interpretation’; in this column he should write what an observer (actually the subject distancing himself/herself from the situation) would be likely to think in those circumstances. At the same time I continued to write behavioral prescriptions in the diary. In addition to attending the university again, he had selected the topic of a course he had already attended for a potential exam. I asked him to attempt to study again, with increasing times of application (15 min first, then 30 min, then 1 h, and so on). He was asked to come back in 2 weeks.
Fourth Session
Tom showed me his diary. He reported several instances of being able to practice self-observation of well-being, to establish a relation between interruption of well-being and thoughts, and to challenge his assumptions, demonstrating that these assumptions were not correct. Two examples are reported in table 3.
Table 3. Fourth session
I was particularly impressed by what he wrote in the observer's interpretation of the second situation: ‘you seek distress’. I had the perception that people like him had a low tolerance for well-being and promptly develop thoughts that may lead them back to distress, the condition that they ultimately believe they deserve. I thought of the patient I had seen with George Engel and his description of ‘pain-prone personalities’ [7].
I thought of my high school studies in Italy. I had attended, like Tom, a ‘classic lyceum’ where Latin, ancient Greek, and philosophy were the main subjects. I was not particularly fond of Latin and Greek (why did we not study English?), but I have to admit that they provided a unique background. A Greek notion was that if things go very well, the gods may become envious and strike you. In many literary situations it was clear that this was because success can make you underestimate the situations, feel invulnerable, and force you into major mistakes. In other words, one can make gross mistakes at the top of success that would not be made before climbing the ladder (there are almost daily examples of these phenomena with politicians, actors, etc.). Other people, however, are not carried out by these feelings of well-being and indeed are convinced that their success cannot last. I also thought of the Roman philosopher Seneca and his idea that well-being was a learning process and that writing could be instrumental.
At this point I was curious to see what Tom would develop for the next time period. I praised his work and encouraged him to come back with more material. I also encouraged him to dedicate more time to studying and social activities. There was a clear-cut decrease in his obsessions: they had become less frequent and less intense.
Table 4. Sixth session
Fifth to Seventh Sessions
The fifth session was also concerned with discussion of the material he had brought with him. In some instances he was unable to provide a valid observer's interpretation and I had to add it. In other cases, what he wrote was fascinating. The time he was able to concentrate was progressively increasing and he had made a tentative plan for an examination. By analyzing the material with him, I had also become aware that some impairments in the psychological well-being dimensions elaborated by Marie Jahoda [8] and Carol Ryff [9] were present and I started discussing them with him. I decided to see him again in a month, to give him more time to progress on his own. The sixth session was very rich with material (a sample is included in table 4).
His observer's interpretations were increasing and rich in philosophical quotations. I explained to him, however, that the diary was not an intellectual exercise that had to be performed after the events. It could be used ‘in vivo’ while experiencing the interruption of well-being, as a way of preventing the obsessions. The obsessions continued to decrease in their frequency, intensity, and in their invalidating impact. I had not applied any cognitive restructuring directed to the obsessive thoughts, only to the thoughts interrupting well-being. I gave Tom an appointment in another month. In the interval he passed an exam very well and immediately started planning another one. After the seventh session, I decided that the end of our therapy was approaching, even though I remained a little skeptical about the stability of the results and was reluctant to see what happened as a therapeutic success. Could this be due to my Greek studies?
Table 5. Last session
Eighth and Last Session
After 1 month, Tom came back. It was difficult to recognize the student I had first encountered. He brought his diary (a couple of examples are outlined in table 5). We discussed how he had got rid of most of his obsessions; his life was changing, he was progressing well to a college degree and he was making plans for studies outside the realms of philosophy. In the seventh session
