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Foreword

      The publication of this first book on Well-Being Therapy (WBT) is a landmark event. Giovanni Fava's pioneering work in developing this powerful and richly layered psychotherapy has stimulated a series of research studies that have shown robust effectiveness for psychiatric disorders. But until now clinicians have not had a manual that spells out the details of treatment delivery and gives specific, session-by-session instructions on how to put WBT into action. The book should promote wider use of a therapy that offers great promise for resolving symptoms and achieving personal balance.

      My introduction to WBT came at an international conference where I had the good fortune to attend a workshop given by Dr. Fava. All I knew in advance of the workshop was that WBT had shown strong results in studies of residual depression and relapse prevention, and that it focuses more on developing positive thoughts and emotions than traditional cognitive behavior therapy (CBT). I was soon to discover that WBT goes far beyond positive psychology and offers a unique treatment method grounded in a multidimensional model of human potential.

      Among the revelations in that first workshop with Dr. Fava, I learned that a practical strategy of keeping a log of well-being experiences could improve mood and reduce symptoms of depression. Having practiced CBT for many years prior to my exposure to WBT, I typically encouraged patients to do thought records that focused on identifying negative or troubling cognitions and emotions. Had I been training them to sharpen their skills in looking for the negative? If they were already accomplished at locking into distressing, self-condemning thoughts, did they need a 180° turn in their thinking? I wasn't ready to abandon the core tenants of CBT. They had helped many of my patients overcome depression and anxiety. And there is an abundance of empirical evidence for the effectiveness of CBT. However, the workshop primed me to try adding WBT methods to standard CBT techniques.

      My first attempt to enrich treatment with WBT concepts was encouraging. I chose a difficult-to-treat situation - a young woman who had been stuck in bipolar depression for over 2 years despite intensive pharmacotherapy. She was living with her parents and unable to work. With crippling low self-esteem, a sense of stagnation and hopelessness for the future, and severely restricted social relationships, she had deep problems in most of the areas of functioning targeted in WBT. Her initial foray with a well-being log was tentative but productive.

      She had been invited to attend a wedding of a friend from high school, but was hesitant to accept the invitation. Yet, she decided to try to shop for a dress to wear to the wedding. Her initial entry on a well-being log captured some experiences that otherwise might have hardly registered in her consciousness. She wrote that the clerk, an older woman, had paid special attention to her and was very kind and supportive in helping her find a suitable outfit for the event. The clerk's encouraging voice and warm smile gave her a sense of well-being that she wouldn't have fully appreciated without taking the time to log it.

      As the therapy progressed, we built upon this first experience to help her recognize and sustain many other episodes of well-being. Eventually such experiences became embedded naturally in her days without the need for logging. In addition to using standard CBT exposure strategies for overcoming patterns of avoidance, we worked on building her self-confidence and self-efficacy with the well-being method that Dr. Fava describes for improving autonomy, personal growth, and other key domains of functioning. The outcome was excellent. At the time of writing this Foreword, she has been free of depressive symptoms for over 7 years, has been working successfully at a demanding job, is living independently, and is engaged to be married. Although all of my attempts at using WBT have not met with this high degree of success, most patients have benefitted. And I have incorporated WBT concepts into my routine work with patients.

      The focus of WBT on six domains of personal functioning gives it an appealing depth that may not be realized in traditional CBT. As Dr. Fava notes, these domains (environmental mastery, personal growth, purpose in life, autonomy, self-acceptance, and positive relations with others) were detailed (in close to the current form used in WBT) by Jahoda in Current Concepts of Positive Mental Health published in 1958. However, there were no attempts to operationalize these constructs into a therapeutic approach until Dr. Fava treated his first case in 1994 and began research that would culminate in his first publication on WBT in 1998.

      Although standard CBT may include methods that target some of the domains (e.g., environmental mastery, autonomy, and self-acceptance), attention to domains such as personal growth, purpose in life, and positive relations with others sets WBT apart as a treatment with a broad, growth-oriented treatment philosophy. This comprehensive perspective on human functioning could link WBT to other valuable methods such as logotherapy, an existentially based method developed by Victor Frankl, and interpersonal psychotherapy. In this first treatment manual on WBT, Dr. Fava gives the greatest detail on the early and middle phases of treatment when well-being diaries and related strategies are used to identify and sustain positive experiences. This alignment toward the more pragmatic and readily conceptualized elements of WBT is understandable and welcome in an initial manual. I look forward to future books that explore the nuances of WBT in later phases that help patients achieve potential and balance in all six domains of functioning.

      Another appealing feature of WBT is its easy integration with other treatment approaches. As Dr. Fava explains in the book, WBT is typically performed as part of a package with traditional CBT methods such as cognitive restructuring, behavioral activation, and exposure and response prevention. Pharmaco-therapy also can be a useful component of the overall treatment plan with WBT. In Breaking Free from Depression: Pathways to Wellness - a self-help guide I wrote with my daughter, Laura McCray, MD - WBT methods are presented (along with standard CBT, medication, and other evidence-based approaches) as one of the key strategies that can be used in an individualized plan to overcome depression.

      Research to date on WBT has centered on depression, generalized anxiety disorder, and cyclothymia. But the core features of the approach suggest that treatment methods could be extended to a variety of other indications such as bipolar disorder, psychoses, and helping patients with symptoms of medical illnesses. Modifications in length and/or focus of treatment might be required. To give one example, treatment of bipolar depression might be performed by a psychiatrist who adds WBT methods to pharmacotherapy over many brief sessions to address chronic symptoms of the mood disorder. I used this modification of WBT in twice-monthly to monthly sessions for more than a year with the patient I described earlier.

      In treatment of the chronic phase of schizophrenia, some studies have shown that CBT methods are helpful for both the positive and negative symptoms of the disorder. Could a well-being approach assist patients with psychoses who have been stabilized on medication and have residual symptoms? In a long-term clinic I established for patients taking clozapine, we typically spend part of the treatment sessions identifying activities that stimulate a sense of well-being, and we discuss themes of personal meaning, positive interpersonal relationships, and other domains identified in WBT. Relapse and rehospitalization rates have been very low in this group of patients, and many have developed an adaptive perspective that helps them understand and cope with their chronic condition.

      An example of a potential treatment application of WBT in the area of medical illness and/or psychosomatic medicine is chronic pain. Could well-being logs from the initial phase of therapy help a person with chronic pain recognize, savor, and prolong experiences that counterbalance and reduce suffering from the medical condition? Could the later phases of WBT help this person tap strengths to build autonomy, self-confidence, and a sense of purpose in the face of the illness? If such changes could be achieved, would the person have a greater level of authentic well-being - not only reduction of pain, or an increased ability