Читать книгу Well-Being Therapy - G.A. Fava - Страница 16

I was wondering about developing a form of psychotherapy based on psychological well-being, but the idea did not seem to materialize. One day, I evaluated Tom, a 23-year-old philosophy student suffering from a severe form of obsessive-compulsive disorder. The disorder was mainly characterized by obsessions related to his girlfriend Laura and had started about a year before. Since then, Tom was unable to study, did not take any examinations, and stopped going to the university. His social life had also been affected. Aside from Laura, whom he kept on pestering with questions about her past, he stopped seeing friends. Tom went to see a psychiatrist, who prescribed fluvoxamine, a selective serotonin reuptake inhibitor. However, the medication did not yield any relief and the psychiatrist switched him to clomipramine, a tricyclic antidepressant drug. Yet, again, no response was observed. These medications were reasonable and appropriate prescriptions on the basis of the available literature. He then underwent cognitive behavior therapy (CBT), but he dropped out of treatment after 6 sessions because he felt he was getting worse. The latter event attracted my attention.

Generally, in the clinical literature no response and deterioration are considered to be the same thing. Yet they are different. In the 1990s, a group of Yale investigators headed by Ralph Horwitz [1] reanalyzed the data of a larger randomized controlled trial that involved the use of a β-blocker after myocardial infarction. Randomized controlled trials are not intended to answer questions about the treatment of individual patients, but to compare the efficacy of a treatment for the average patient who is randomly assigned to one of the groups. Horwitz et al. [1] analyzed the trial in a different way, according to subgroups characterized by specific clinical histories. They found that the β-blocker was helpful for the ‘average’ patient who survived an acute myocardial infarction, whereas it was harmful in a subgroup characterized by specific cotherapy histories.

If we accept the possibility that a treatment which is helpful on average may be ineffective in some cases and even harmful in someone else, we may learn that a given therapy may not be of value for a particular class or subgroup of subjects who present with certain clinical characteristics [1]. Big Pharma, which together with biotechnology corporations substantially controls medical publications and information [2], does not like to hear about the subgroup which gets worse, probably because it may scare potential customers. Yet these events occur with any drug. I have studied the paradoxical reactions that may take place with antidepressant drugs (when medications deepen the depressed mood) [3]. Clinical worsening may also occur with psychotherapy. The various psychotherapy schools also do not like to hear about negative effects [4].

In clinical pharmacology, adverse events may be due to the fact that the physician did not prescribe the drug appropriately (e.g., at a dosage that is excessive or inadequate); however, in this case treatment was correct. In psychotherapy, negative effects may arise because of psychotherapy that is not properly conducted [4]. However, in the case of Tom, I knew the psychologist who used CBT and held him in high regard for his competence and skills, particularly in obsessive-compulsive disorder. I thus felt that every reasonable approach had been attempted. What could I do that was different? I thought on the substantial distinction that Tom made: drugs did not help him, while psychotherapy made him worse.

I formulated a hypothesis. The basic mechanism of cognitive therapy lies in monitoring distress: identification of the situations where it occurs leads to finding the negative thinking (automatic thoughts) that is associated and precedes the negative emotions (fig. 1). Yet, in the case of Tom, this mechanism probably leads to deepening of distress. What about doing the opposite: monitoring well-being and looking at what interrupts it (fig. 2)? So I told Tom that he had to keep a diary where he should report the instances of well-being. I did not provide any definition of well-being, but I asked him to write down the situations when he felt good, what he experienced, and its intensity. His comment was not encouraging: ‘It will be a blank diary.’

Fig. 1. Basic mechanism of cognitive therapy.

Fig. 2. Basic mechanism of Well-Being Therapy.