the idea of closing therapy (I must say that at the beginning of our encounters, because of the novelty of my approach, we had not agreed upon a specific number of sessions). I asked him whether he was ready to go on by himself. He said yes with a lot of determination. I told him, as I always do with my patients, that in any case, for any reason, I was there. He could call me or come to see me. Nonetheless, I wanted to see him in a year to check his progress. I expressed my sincere gratitude to him for the things I had learned through our encounter. One year later, he was fine and had just started a Master's course in marketing - Tom confided ‘too much philosophy is not good for me’. I am very proud of him and of his subsequent accomplishments in life.
Posttherapy Reflections
Soon after the therapy was over, I started wondering what had actually happened. I remember one day in Albuquerque I was discussing a case with a resident in psychiatry and my mentor Robert Kellner during the weekly meeting of our psychiatric unit. A patient was not responding to treatment and I had decided to switch her from one drug to another. She had improved very much and rapidly, and I suggested a possible neurotransmitter mechanism for it. The resident had a different view in terms of receptor modifications and we started a lively discussion.
We did not notice that a nurse was trying to say something, unsuccessfully. But during a pause of our debate she said, ‘I do not know how to tell you this, docs. But the truth is that we forgot to change the medication and the patient is still taking the old one.’ I wished I could have magically disappeared from the room. I was so ashamed of myself and of our silly discussion. But Robert Kellner was, as always, very kind and supportive and explained:
This case offers a very good lesson. When a patient gets better, the most likely explanation and the one you should keep in mind is that this has nothing to do with what you did, prescribed, or said. There are many potential explanations you may not be even aware of. Only controlled studies may ascertain whether there is something therapeutic in what you are doing.
So my first reaction was: who knows what made Tom get better? Maybe it was the quality of our relationship, my stories, or something that happened to him in the course of therapy. I had found a road to recovery that was not the usual one, but I needed to test it in a scientific way.
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
