Well-Being Therapy: A Guide to Long-term Recovery

Giovanni Fava
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If a patient has high cholesterol or sugar, the doctor may prescribe a drug to lower what is too high, but he/she generally adds some suggestions: for instance to avoid certain types of food, to do more physical activity, to refrain from smoking. What the patient does is defined as self-therapy or self-management and is at least as important as a drug that is prescribed. But if someone has a low mood and seeks medical help, the doctor–particularly if he or she is a psychiatrist–will likely just prescribe a drug and not encourage any “self-therapy.”

The problem with his approach to care is that psychiatric drugs, even when they are properly prescribed, may help very little in the long run and create a number of additional problems.(1)

In the 1990s, I became particularly concerned about the high risk of relapse in depression and its link with residual symptomatology (2). Other investigators became similarly concerned. It was not easy to help patients get better, but it was even more difficult to help them keep well. I was looking for a psychotherapeutic strategy that could increase the level of recovery, that could enhance self-therapy, that could build on a person’s resources. This was the setting where I developed a psychotherapeutic technique for increasing psychological well-being, which I dubbed Well-Being Therapy (WBT) (3).

This specific psychotherapeutic technique for increasing psychological well-being and resilience has been validated in a number of randomized controlled trials (4). It is a short-term strategy, that emphasizes self-observation, with the use of a structured diary, interaction between patients and therapists, and homework. Patients are encouraged to identify episodes of well-being in a diary and to set them into a situational context. 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 (automatic thoughts), as is performed in cognitive therapy.

However, the trigger for self-observation is different, as it is based on well-being instead of distress. Cognitive restructuring along dimensions of psychological well-being may then take place; activities that are likely to elicit well-being and optimal experiences are encouraged. The findings from controlled studies indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one’s self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage affectively one’s life, and a sense of self-determination. A decreased vulnerability to depression and anxiety also has been demonstrated after well-being therapy in high-risk populations (5, 6).

I have written a manual for its use (4), with information that is useful for patients who want to pursue self-therapy that may help them obtain recovery. The book consists of 3 parts. The first describes how WBT was developed and how it was validated by a number of controlled trials. The second part outlines the type of assessment that is necessary for its application and provides the treatment manual, session by session, with descriptions of clinical cases. The third part deals with the current indications of WBT based on controlled studies and other potential applications: depression, mood swings, generalized anxiety disorder, panic and agoraphobia, post-traumatic stress disorder and the interventions in school settings. It is a detailed clinical account about how to use WBT in those settings. It is not a self-help book, but it includes information that pharmaceutical propaganda does not make easily available and may be crucial for the management of mood and anxiety disorders.

References

  1. Fava GA: Rational use of antidepressant drugs. Psychother Psychosom 2014;83:197-204
  2. Fava GA: The concept of recovery in affective disorders. Psychother Psychosom 1996; 65: 2-13.
  3. Fava GA: Well-being therapy: conceptual and technical issues: Psychother Psychosom 1999; 68: 171-179.
  4. Fava GA: Well-Being Therapy. Treatment Manual and Clinical Applications.   Basel, Karger, 2016.
  5. Fava GA, Rafanelli C, Grandi S, Conti S, Belluardo P: Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings. Arch Gen Psychiatry 1998; 55: 816–820.
  6. Fava GA, Ruini C, Rafanelli C, Finos L, Conti S, Grandi S: Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. Am J Psychiatry 2004; 161: 1872–1876.

14 COMMENTS

    • Maybe it’s mostly in Italian.

      In my opinion, Dr. G. Fava is one of the good guys. He acknowledges antidepressant withdrawal. Some psychiatrists still regard it as relapse or recurrence, and use it to push patients stay on drugs for-ever. (There’s an M. Fava in the field as well; he’s a conventionalist.)

  3. I am against medication, but my therapist is terrible. I have been seeing him for 7 years and he would see me for 10 minutes at a time, or not see me at all and still bill the government for services.

    After I mentioned this to him and that I wanted him to see me the whole 40 minutes he bills for, he started to provoke me into anger which is part of his therapy where he makes people speak up for themselves by provocation, who are socially anxious and submissive.

    It is terrible that I can’t even get proper therapy from a counselor, I am in the process of reporting him but it is a bigger problem, a systemic problem.

    Therapists don’t take patients who are severely unhappy because it increases their workload, they see a lot of patients to make a lot more money since they don’t get paid as much as psychiatrists, who make more money from office visits of 10 minutes and prescribing medications.

    The whole system is messed up, it is very hard to rely on self help alone as in this article but it is my saving grace. I try to manage diet, exercise, I’ve tried fasting which helps people who are sad, though a quality therapist who is there to always encourage you and make you feel good about yourself is so desperately needed.

    Please America, fix your mental health system so its humane!

      • He is not lazy he is a typical therapist in America.

        Therapist shopping isn’t going to help, it takes a few months just to get comfortable and establish a good working relationship with one to begin with.

        Everywhere you go you hear the story of therapists treating clients like cattle, rushing them in and out of the office for more money.

        Look at the systemic failure of psychiatrists, who don’t even provide talk therapy anymore but just make a quick diagnosis and put you on medication.

        The system is broken, self help or self therapy is how you help yourself in an unhelpful society.

        After several years with one, I’ll move on to my second one because of my convictions against medications to treat natural emotional reactions to an unjust society.

  4. Dr. Fava, thank you for your research. I needed that kind of thing so much more than zoloft or prozac when I was undergoing severe depressing thoughts. Belief that I can do more than pop pills to help my unhappiness makes me feel empowered.

    I hope you will publish more and have it translated into English!

  5. I agree, keeping a journal is a wonderful way to help one heal, I know doing such (outside medical advise) was one of the things that saved me when I was dealing with a psychiatric system that doesn’t listen to their patients, doesn’t believe their patients, and in my case, once I’d read some of my psychiatrist’s notes, realized how deluded he was, and confronted him, he even declared my entire life and everyone in it to be a “credible fictional story.” Of course that’s when one realizes how, not only stupid, but staggeringly unethical one’s doctor is, and walks away forever. But, absolutely, journaling is a wonderful way to figure out what needs to be figured out, and it’s almost free.

    And I absolutely agree, lying to patients with claims of proven “chemical imbalances” and brainwashing people’s families into thinking the scientifically invalid DSM disorders are “life long, incurable, genetic mental illnesses,” when that’s contrary to the actual medical evidence, is an extremely pessimistic way to treat a person, in addition to being disingenuous. The psychiatric industry really needs to rethink the wisdom of functioning as a gas lighting industry, since gas lighting people is mental abuse, not mental health care. Good luck with your manual.

    • VERY BAD NHS MEDICINE,

      I discovered my GP Surgery using my name on a Severe Mental Illness Register in 2012 :- nearly 30 years after I had recovered, and I complained straight away.

      I had a consultation with a doctor shortly afterwards (where I discussed the subject) and I later applied for the notes.

      The Doctor had written that : “…there was no sign of self neglect, that the eye contact was normal. That there was no thought disturbance but that there was mild agitation. That there was current functioning…”

      The Doctor could equally have represented me as “… Very well but concerned about their name being included on a Mental Health Register…”

      (I’d also been currently functioning for the previous 26 years in the UK, mostly on Building Sites).

      • “Functioning for 26 years, mostly on building sites” is an awesome thing to request to be added to your mexical records!

        I once saw on my notes “mental health status seems normal but at times uses pressured, rapid speech”

        I pointed out to the doctor that he seemed to have gained his medical degree in the city where I was born, and I asked if he had noticed any other incidences of “pressured, rapid speech” from people in that area. He had the decency, at least, to apologise for pathologising, by implication, a whole densely populated area of England, based on dialect and speech patterns alone…

    • Someone Else,

      I do like the word gaslighting.

      I was told by the GP Practice Manager that my Records and Diagnosis were no longer on the system. I did have some interaction with the Information Commissioner, and I have now been told the Practice Manager is resigning.

      I had a meeting with the Senior Partner on the subject of my now missing “Mental Health Record and Diagnosis” – and afterwards was provided with a copy of the notes.

      At the end of the notes he stated that I had claimed my previous doctor had resigned on account of mental illness.

      My previous doctor that had put my name on the Severe Mental Illness Register DID leave himself on account of his own Severe Mental Illness which he has described as “Burnout”.

      On June 18, 2015 my ‘burntout’ doctor (in a trade journal) writes:-

      “…Eventually burnout came and took me away. I have taken steps to recover and after 4 months gap summer have returned to practise P/T but not in the NHS anymore….”

      (Burnout – my arse!)

  6. Great article. Read about the Cast Trial:

    “The Cardiac Arrhythmia Suppression Trial (CAST) was a double-blind, randomized controlled study designed to test the hypothesis that suppression of premature ventricular complexes (PVC) with class I antiarrhythmic agents after a myocardial infarction (MI) would reduce mortality. It was conducted between 1986 and 1989 and included over 1700 patients in 27 centres.[1] The study found that the tested drugs increased mortality instead of lowering it as was expected.[2] The publication of these results in 1991/92, in combination with large follow-up studies for drugs that had not been tested in CAST, led to a paradigm shift in the treatment of MI patients. Class I and III antiarrhythmics are now only used with extreme caution after MI, or they are contraindicated completely.[3] Heart Rhythm Society Distinguished Scientist D. George Wyse was a member of the CAST trial’s steering and executive committees.”

    “The drugs used (encainide, flecainide, and moracizine) successfully reduced the amount of PVCs, but consequently led to more arrhythmia-related deaths. Total mortality was significantly higher with both encainide and flecainide at a mean follow-up period of ten months. Within about two years after enrollment, encainide and flecainide were discontinued because of increased mortality and sudden cardiac death.”

    This is a great example of followup science. The cardiologist had to know whether the drugs they prescribed were helping people. They had no idea that suppressing PVC’s was harming patients. This required a large and powerful multi-center study.

    At this point, even JAMA recognized that this needs to be done especially in children. We do not know if drugs being prescribed to children are harming them in the long run. Children cannot give true consent. Their parents sign for them. Current theories in medical ethics suggest that parents still must do what is best for a child. Thus a parent who is against a blood transfusion cannot prohibit a blood transfusion that would save a child’s life.

    From the data, CBT is very helpful for anxiety, anger management, behavioral modification. Psychotherapy is more effective for depression. WBT appears to be a form of positive structured psychotherapy. The benefit of CBT is that it is a form of education, and children really benefit, and there are no side effects, but it requires effort. WBT also seems to involve emotional effort, and adults benefit from listening to other adults. The reality is that a pill is a product that requires no effort. You do not even need to look up the chemical structure, you just take the pill.

    From what I can see, CBT and Psychotherapy are a form of learning. You are learning to cope, how to deal with your issues. Taking a pill is a buffer, it suppresses learning as nearly everyone will attest to. This can be demonstrated by testing long term memory functions. When people take medications, they often have far softer memories. The entire purpose of psychotherapy was to access memories, and to use those memories to prepare yourself for the present and thus the future. The entire purpose of CBT is to learn a general outline of reinforcement, to remember a way to think and act. It is not clear how medication in the long term facilitates the memory process, although in the short run, medication can often demonstrate effectiveness when compared to placebo.

    But as was demonstrated in the CAST trial, short term effectiveness is different than improvement in mortality. CAST demonstrated that short term effectiveness can increase mortality. This was also demonstrated with Welbutrin, which GSK hid, and was the subject of a multi-billion dollar liability. Retrospectively, you would expect that a buytl substituted amphetamine might increase impulsiveness. Thus, patients on Wellbutrin felt “better” but committed suicide at a higher rate. The point was not that they were depressed, but that the medication affected the right frontal lobe, hyper stimulated delta FosB and made them impulsive, and they acted on their impulses, hence the paradoxical higher rate of suicide, no different than the CAST trial where suppressing PVC’s during myocardial ischemia led to increased mortality.

  7. I was happy to refuse “medication” at the start in 1980 but when I tried to stop depot injection in 1983 I quickly realised that I honestly couldn’t go without it. When I was in hospital that time I got talking to a Psychologist and he assured me that everyone could recover without “medications”.

    But after a series of hospitalizations what I eventually discovered was that the drugs (like all tranquillisers) had withdrawal syndromes. My Psychiatrist didn’t seem to know this – he was operating off the assumption that my difficulties were relapses.

    But eventually I did get clear and made full Recovery through Psychology.