Well-Being Therapy. G.A. Fava

happiness, but an overarching, metapsychological well-being that enriches his or her life and limits the impact and reach of pain?

      An additional idea for the expansion of WBT is to embrace technological advances in treatment delivery. Work on development and testing of computer-assisted CBT has expanded rapidly in recent years and has shown excellent results in many studies. The goals of computer-assisted CBT include improving access to effective treatment, reducing cost of therapy, enhancing the therapy experience with multimedia learning experiences, and providing tools for tracking and promoting progress. Programs have been developed for depression, anxiety disorders, eating disorders, substance abuse, chronic pain, and other conditions. WBT methods could potentially be provided via fully developed computer programs for treatment or mobile apps that could augment the efforts of human therapists and help clinicians treat more patients with available time.

      With the publication of this treatment manual, a new phase in the development of WBT begins. Guidelines are now laid out for clinicians to use this inventive approach in everyday practice. Dissemination among much larger populations of patients can be envisioned. Development of well-being methods for more diverse clinical problems can be projected and supported with a core text on basic theories and procedures. Research on treatment outcome in depression, anxiety, and a variety of other conditions can be anticipated. And innovative delivery methods with computer technology can be conceptualized. Patients and therapists owe a debt of gratitude to Giovanni Fava for introducing WBT into the family of effective psychiatric treatments.

      Jesse H. Wright, MD, PhD, Louisville, Ky.

      ______________________

Preface

      This book is both the first full account and a manual for a specific psychotherapeutic strategy for increasing psychological well-being: Well-Being Therapy (WBT).

      The first part describes how it developed and how it was implemented. The second part outlines the type of assessment that is necessary for its application and provides a session-by-session treatment manual. Finally, the third part deals with the current indications of WBT based on controlled studies and other potential applications, with descriptions of clinical cases.

      For this book, I am indebted in particular to Jenny Guidi, PhD; Elena Tomba, PhD; Emanuela Offidani, PhD; Jesse H. Wright, MD; Seung K. Park, MD; Fiammetta Cosci, MD, PhD; Chiara Rafanelli, MD, PhD; and Nicoletta Sonino, MD (my wife), who provided important feedback and encouragement.

      Giovanni A. Fava, MD, Bologna/Buffalo, N.Y.

Part I: THE DEVELOPMENT

      ______________________

Chapter 1

       The Background

      When I decided to study medicine, I was not particularly convinced of my choice. The early years were tough: I did not like the topics I was studying in my medical school in Padova, Italy. I was aware that I should consider myself lucky with a future full of promise, but I kept on wondering whether it was the right choice - until something happened. In those days (early 1970s), medical students had yearly chest X-rays. At the beginning of my third year (medical courses extend over 6 years in Italy), I had mine. A few days later I received a letter stating that there was something wrong and to come back for further checking in a couple of days. My first thought was ‘I have tuberculosis’. When I got the letter, I was reading Thomas Mann's Magic Mountain and I concluded that this could not be a coincidence: ‘I have not been feeling well, recently - I thought - I am more tired than I used to be.’ I imagined myself in a sanatorium, far away from my family, friends, and classes. When I eventually went to the clinic for the new check-up, I was a wreck. But at the clinic they told me there must have been a mistake and that my chest was fine. In a matter of seconds, I felt fine and when I left the clinic the sky was blue and there could not be any other medical student happier than I was. I understood that regaining health is a wonderful experience; however, I was never actually sick from a medical viewpoint.

I thus became interested in psychosomatic medicine, a comprehensive framework for assessing the role of psychosocial factors in the development, course, and outcome of illness [1]. However, no one seemed to be interested in psychosomatic medicine in Padova or at other Italian universities. By some lucky circumstance, in 1975 I was able to spend the summer in Rochester, New York, studying with one of the most prominent scholars in the psychosomatic field, George Engel.

      The Rochester Experience

George Engel was Professor of Medicine and Professor of Psychiatry at the University of Rochester School of Medicine and Dentistry. Trained as an internist, he had criticized the traditional concept of disease being restricted to what can be understood or recognized by a physician [2]. In other words, only the physician could decide if something is a disease and if a patient can be sick. Engel elaborated a unified concept of health and disease [2]: there is no health and no disease, only a dynamic balance between health and disease. Such a view, expressed in 1960, was subsequently elaborated in the biopsychosocial model [3]. Psychosocial factors are a class of etiological factors in every type of disease, but their relative weight may change from one disease to another, from one patient to another, and even from one episode to another of the same illness in the same patient [4]. It is not that certain diseases, defined as ‘functional’, lack an explanation, but rather it is our assessment that is inadequate in most clinical encounters [5].

I spent the summer in his medical-psychiatric unit and the experience was for me an endless source of knowledge and inspiration. One day a psychosomatic consultation was requested from a medical ward. With another medical student, Sam, I went to see the patient. She was a lady in her fifties and manifested what appeared to be an unbearable abdominal pain. Medical work-up could not establish a potential cause. Her condition seemed to be deteriorating and explorative surgery was planned in a couple of days (in 1975, today's minimally invasive explorative procedures were not available). Our job was to interview her and get some preliminary history. Dr. Engel would have come later in the day. We started with some questions, but she appeared to be in great pain. Sam and I agreed that it was probably not the right time and should come back with Dr. Engel, which we did. Dr. Engel immediately got her attention and collaboration. At a certain point during the medical interview, he became interested in a scar the patient had. The lady suddenly brightened up and described a past surgical operation. Dr. Engel asked whether she had undergone other surgical interventions. The lady showed other scars and provided detailed descriptions of each surgery. She seemed to forget about her pain. Sam and I could not understand what was going on. She looked so well, while only hours earlier she was in so much pain. Dr. Engel asked how things were going in her life and she replied that after a very troubled time with a lot of problems in her family things were going reasonably well. When we got out of her room, Dr. Engel told us that the lady had a pain-prone personality and was a surgery addict [6]. When life is treating these patients worst, when circumstances are the hardest, their physical health is likely to be at its best and the individuals are free of pain. When things improve, when some success is imminent, then painful symptoms develop [6]. Sam asked what could be done for these