Well-Being Therapy. G.A. Fava

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СКАЧАТЬ 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 patients. Dr. Engel replied ‘Not much, unfortunately. I will speak with her physician and at least this time we will avoid surgery.’ Sam and I, with our juvenile wish to help, were very dissatisfied by that answer. I thought ‘Maybe one day someone will find the way.’

      When the summer was over, I went back to Padova and intended to become like George Engel and be knowledgeable of both internal medicine and psychiatry. In due course, however, I realized that one specialty was already more than I could handle and thus chose psychiatry, the field where most of the psychosomatic researchers came from.

      Treating Depression

I started my residency training program in psychiatry in Padova, but my idea was to go back to Rochester to complete my training. Due to certain circumstances that in those days I judged to be unfavorable, I ended up instead in Albuquerque, New Mexico. My teacher and mentor was someone I had met at a psychosomatic conference, Robert Kellner. He had become a psychiatrist after several years as a primary care physician and thus shared something in common with George Engel. He really showed me how the psychosomatic approach could balance pharmacological and psychological therapies in psychiatric practice. Depression was the psychiatric disorder that attracted my attention the most. After 1 year in the southwestern US, I moved to Buffalo, New York, where I was asked to establish a depression unit. I was convinced that depression was essentially an episodic disorder, that there were powerful remedies against it (antidepressant drugs), and chronicity was essentially a consequence of inadequate diagnosis and treatment. Today when I look back on of my views then, I am surprised of my naiveté and clinical blindness. We have become aware that depression is essentially a chronic disorder with multiple acute episodes along its course [7]; however, back then my view was shared by almost every expert in the field.

      Working in the US, I had essentially a cross-sectional view of the disorder (I was seeing and treating patients only in the hospital, with little follow-up). However, when I decided to go back to Italy and establish an outpatient clinic at the University of Bologna with opportunities for follow-up, I began to observe that patients I had personally treated with antidepressant drugs and whom I judged to have completely remitted relapsed into depression after some time. What was I missing?

      The Concept of Recovery

I became more and more skeptical of the long-term effectiveness of antidepressant drugs to the point that in 1994 I introduced in the literature the hypothesis that these medications could be a cause for chronicity [8]. I was inspired by the ‘antibiotic paradox’: the best agents for treating bacterial infections are also the best agents for selecting and propagating resistant strains, which persist in the environment even when exposure to the drug is stopped [9]. On the basis of some data that were available, I postulated that long-term use of antidepressant drugs may worsen the long-term outcome and symptomatic expression of illness, decreasing both the likelihood of subsequent response to pharmacological treatment and duration of symptom-free periods [8]. Two decades later the evidence supporting this hypothesis is quite impressive [10], but in those days swimming against the tide of pharmaceutical propaganda was not easy. In Albuquerque, under the guidance of Robert Kellner, I had learned to practice cognitive behavior therapy (CBT). I used it with my depressed patients, whether associated with antidepressant drugs or not, but it did not seem to affect their long-term outcome, as also reported in the literature [7]. This was in striking contrast to the use of CBT in anxiety disorders, where positive and lasting effects could be observed [8].

Meanwhile, more and more studies were pointing to the fact that pharmacological treatment of depression was not solving all the problems and, despite substantial improvement, important residual symptoms were present [11]. Such symptoms included anxiety and irritability in particular, and were associated with impaired functional capacity. Most residual symptoms also occurred in the prodromal phase of illness and might progress to become prodromal symptoms of relapse [11]. As a result, the concept of recovery could not be limited to the abatement of certain symptoms [12]. As Engel indicated [2, 3], health is not simply the absence of disease, but also requires the presence of wellness. We knew how to bring people out of the negative functioning, but regaining psychological well-being was quite different and we did not have a clue about how to achieve it.

      Psychological Well-Being

In the mid-1990s, I attended an international conference on psychiatry in Copenhagen, organized by my friend Per Bech, one of the most important and original researchers in psychological assessment of mood disorders [13]. When I met him, he recommended attending a session on quality of life. He explained that one of the speakers was an American developmental psychologist who had some interesting ideas. I went and, as on other occasions, he was right. The speaker was Carol Ryff, who gave an account of her model of psychological well-being, which was a synthesis of various contributions from the literature [14]. She remarked that well-being cannot be equated with happiness or life satisfaction. She had developed a questionnaire for measuring the various dimensions of psychological well-being, the Psychological Well-Being Scales (PWB), which she had applied to nonclinical populations in longitudinal studies [14]. She gave a brief description of each of its six dimensions.

      I belong to the endangered species of clinician-researchers who do clinical research as well as assess СКАЧАТЬ