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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 and treat individual patients. When I examine research constructs, my starting point is always whether these constructs make sense with the patients I see. And Ryff's formulations were able to do this: autonomy (a sense of self-determination), environmental mastery (the capacity to manage effectively one's life), positive interpersonal relationships, personal growth (a sense of continued growth and development), purpose in life (the belief that life is purposeful and meaningful), and self-acceptance (a positive attitude toward self). After her presentation, I started thinking of many patients I had encountered who seemed to have these dimensions impaired or exaggerated with resulting clashes against everyday life. I was surprised that a developmental psychologist could have articulated such deeply clinical formulations.

Many years later I discovered that those dimensions had indeed a clinical root and were developed by Marie Jahoda, Professor of Social Psychology at New York University, in a fantastic book on positive mental health that was published in 1958 [15]. The book was waiting for me in an American library and became a further source of reflection and inspiration. Marie Jahoda had outlined six criteria for positive mental health. In 5 cases these criteria were only slightly different compared to those later outlined by Carol Ryff: autonomy (regulation of behavior from within), environmental mastery, satisfactory interactions with other people and the milieu, the individual's style and degree of growth, development and self-actualization (this was split by Ryff into the dimensions of personal growth and purpose in life), and the attitudes of an individual toward his/her own self (self-perception/acceptance). There was, however, a sixth important dimension whose formulation became particularly important to me at some later point in time: the individual's balance and integration of psychic forces, which encompass both outlook on life and resistance to stress.

Implementing a psychological work aimed at improving psychological well-being appeared to be quite difficult and I did not know how it could be achieved. In 1954, Parloff et al. [16] suggested that the goals of psychotherapy were not necessarily the reduction of symptoms, but instead increased personal comfort and effectiveness. However, there had been a very limited response to these needs in subsequent years. Notable exceptions were Ellis and Becker's A Guide to Personal Happiness [17], a modification of rationale-emotive therapy for removing the main blocks to personal happiness (shyness, feeling of inadequacy, feeling of guilt, etc.), Fordyce's program to increase happiness [18], Padesky's work on schema change processes [19], Frisch's quality of life therapy [20], and Horowitz and Kaltreider's work on positive states of mind [21]. Unfortunately, these approaches had not undergone sufficient clinical validation and did not seem to target what I had in mind in terms of psychological well-being.