Putting Well-Being at the Center of Therapy Rather than Depression

Patient Expert

Whenever I've looked for depression treatment, I've always wanted help with one basic thing: Stop the pain And that's what most therapies for depression try to do. They focus on what's wrong and try to get those symptoms into remission. If it works, and you feel a lot better, the good stuff of living takes care of itself. In other words, health is defined as the absence of illness rather than the presence of well-being.

There's a lot of research, however, pointing to a big problem with the symptom remission strategy. Only a minority of patients fully recover from a major depressive episode. The rest don't quite get rid of all the symptoms, and it turns out that these leftovers are an excellent predictor of recurrence. Relapse is a huge issue, as so many of us know, but it's only in the last 15 years or so that new therapies have been developed specifically to deal with it.

One of these is Well-Being Therapy (WBT), and it turns the usual treatment approach on its head. Instead of starting with everything that's wrong, it starts with everything that's right. Though it falls under the general heading of Positive Psychology, WBT is quite different from any approach based on thinking positively and banishing negative feelings. The idea of well-being that underlies the therapy is not just about feeling good. It's primarily about strengthening the capacity to lead a fulfilling life.

WBT uses six major dimensions to define well-being, each ranging along a spectrum from completely positive to completely negative.

Environmental mastery: Having a sense of competence in managing everyday life as opposed to feeling that everything around you is beyond your control.

Personal growth: Open to new opportunities and feeling steady development in your life, as opposed to feeling like you're stagnating and unable to change.

Purpose in life: Having goals, a sense of direction and purpose in your present life as well as your past, as opposed to believing your life has no meaning and lacks direction or goals.

Autonomy: Independent, self-motivated and able to resist social pressures, as opposed to depending on others for approval and relying on their judgment instead of your own.

Self-acceptance: Feeling good about who you are and accepting of both good and bad qualities, as opposed to always being dissatisfied with yourself and wanting to be different than you are.

Positive relationships: Able to form warm and trusting relationships and feel empathy and affection for others, as opposed to being isolated from people and frustrated in most relationships.

What I like about characterizing well-being in this way is the recognition that a fulfilling life is a complicated thing. This approach doesn't try to fit you into a preconceived norm of "happiness." It's flexible enough to allow you to work in your own way on those dimensions that you most want to improve.

Well-Being Therapy is a short-term strategy, designed to be completed in 8 weekly sessions. If you put yourself into this picture, the therapist would work with you through three phases of two or three sessions each. But the process doesn't start with a lecture about the six dimensions and all the characteristics of each one. Those can be introduced later, one at a time, as you identify more clearly what you're going through.

Instead, you start with intensive work of self-observation. You would be asked to keep a detailed, structured diary recording every experience that gives you a sense of well-being.

Now, if I were doing this while dealing with residual symptoms or relapse, I'd likely hand the fresh diary back to the therapist, saying something like "I might as well return this right away because it will look just as clean and blank next week as it does now." Apparently, I wouldn't be alone in doing that. Many participants feel the same way: I never feel like I'm well. What's there to write about?

If you were doing WBT and said that, it would be the cue for the therapist to point out that there are always good moments, no matter how fleeting. The problem is that you usually don't notice them - or don't believe in them.

I think that's true. When I've been depressed, sometimes I've had the odd feeling of satisfaction or realize that I've done something right for a change. However, I throw that out because "it doesn't count." It's just a fluke or dumb luck. Or I bury it in shame since I don't have a right to feel good about anything I do. Whatever the explanation, I banish the experience, and I may not remember it at all.

If this were a diary of depression symptoms and moods, I could fill it to overflowing, and very likely you could too. But it takes discipline for a depressed person to stop and write down those flashes of well-being. It's hard to claim ownership of anything good, but that's what you have to learn to do during WBT.

In the next phase, the therapist works with you to figure out what interferes with those moments of well-being and find methods to keep the experience alive for a longer time. Cognitive therapy and mindfulness techniques can be used to help you stay with the sense of wellness and stop your mind from immediately dismissing it.

The final phase is the time to look at the overall scope of your diary, focusing only on those aspects of the six dimensions that are relevant to what you've written down. The diary is always the guide, not the abstract definitions. The dimensions give you useful ways of thinking about yourself and help you identify the best ways you can work on whatever you're trying to change. Then you can focus on learning the most effective methods that you can continue to use long after the sessions are over.

All this resembles some aspects of cognitive therapy, but what I find new and most challenging is the change of focus. Learning how to prolong and deepen the experiences of well-being rather than simply end the worst symptoms of depression is something I haven't done before in a disciplined way.

That's the point. In all the years I've done therapy, I've spent endless hours analyzing all the dimensions of depression but almost none thinking about well-being. Learning how to refocus on whatever good moments there are and make them the basis for change is a whole new discipline for me.

It's not the answer to every problem, but it seems like one more good tool to support the process of recovery.

Do you think it would be helpful for you?