What Is Wellbeing Therapy & How Does It Work?

Psychotherapy has traditionally been focused on healing people and bringing them up to their usual level of functioning.

While addressing psychological ailments is crucial for improving mental health, it falls short in terms of helping people achieve optimal functioning. Since its inception, positive psychology has highlighted the need to increase wellbeing as much as to improve ill health to enable people to flourish.

Clinical psychological interventions have the potential to offer a wider range of benefits by combining effective therapeutic techniques with the science of wellbeing. This combination may allow clients to not only overcome their ailments, but also to develop their full potential, build resilience, and live more fulfilling lives.

This article explores a psychotherapeutic approach aimed at improving both mental health recovery and wellbeing.

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What Is Wellbeing Therapy?

In the late 1990s, the Italian psychiatrist Giovanni Fava was in search of a psychotherapeutic approach able to improve the recovery rate for people experiencing depression and anxiety disorders.

Although approaches such as CBT have demonstrated high levels of success in effectively treating these conditions, they seem less effective in tackling the relapse and recurrence of such disorders (Fava & Ruini, 2003).

Wellbeing Therapy (WBT) emerged as a response to fill this gap in clinical psychology.

The gap in psychotherapy

Fava and Ruini (2003) distinguished different elements that were missing in psychotherapeutic approaches that contributed to the birth of WBT.

1. Recovery, relapse, and recurrence

Any mental health treatment aims to achieve full recovery, which means not presenting symptoms for several months (Frank et al., 1991). After reviewing evidence, Fava and Ruini (2003) argued that treatments were less centered on recovery and more focused on preventing relapse, which is the return of symptoms before recovery takes place and once remission (being symptom free) starts occurring (Frank et al., 1991).

Ramana et al. (1995) found that almost half of clients experienced a recurrence of depressive symptoms after a year of finalizing their treatment, meaning that they experienced another depressive episode.

Evidence suggests that the Quality of Life assessment was better able to predict the recurrence of depression than scales measuring symptoms (Thunedborg, Black, & Bech, 1995), which pinpoints the relevance of focusing on developing wellbeing resources.

2. Confusing response with recovery

Fava and Ruini (2003) state that clinicians and psychotherapists tend to misperceive response to treatment with recovery, arguing that experiencing remission according to the Diagnostic and Statistical Manual of Mental Disorders is not enough evidence for a full recovery. Thus, the need to incorporate the dimensions of psychological wellbeing in the definition of recovery was proposed.

3. Positive health and the growth of positive psychology

The notion of health as comprising both the freedom of illness and the presence of wellbeing took off strongly after the advent of positive psychology in the early 2000s.

Clinical researchers started to increasingly value the use of positive health measurements to broaden the scope of evaluation for treatment success (Fava & Ruini, 2003). Hence, positive psychology provided further support to incorporate wellbeing measurements and interventions within clinical psychology.

The origins of Wellbeing Therapy

WBT was envisioned as a therapeutic strategy for enhancing psychological wellbeing (Fava, 2016). According to Fava (1999), before the development of Carol Ryff’s (1989) multidimensional model of psychological wellbeing, there was a tendency in the field to conceive wellbeing as the absence of distress or illness. Consequently, therapeutic techniques aimed mainly at the reduction of symptoms.

However, research suggested that a great number of patients with anxiety and mood disorders experienced residual symptoms after completing their traditional treatments (Fava, 1996). This novel therapy offered a way to address this gap, aiming to minimize residual symptoms and enhance psychological wellbeing.

WBT is defined as a short-term psychotherapeutic technique based on the six dimensions of psychological wellbeing, namely

• self-acceptance,
• autonomy,
• environmental mastery,
• personal growth,
• purpose in life, and
• positive relationships (Ryff, 1989).

Using a combination of interactions between the client and the therapist, a structured journal, and homework, this approach underscores the client’s self-observation in each dimension of psychological wellbeing.

In its early stages, WBT typically unfolded over four to eight weekly or bimonthly individual sessions that lasted between 30 and 50 minutes (Fava, 1999). WBT was referred to as “structured, directive, problem-oriented, and based on an educational model,” complementing and following other therapeutic approaches such as Cognitive-Behavioral Therapy (Fava, 2016).

Later on, WBT started to be utilized as a standalone psychotherapeutic strategy, comprising 8 to 20 sessions of 45 to 60 minutes each. It has also shifted from being exclusively applied in a classic individual setting to couples, families, and group modalities (Fava, 2016).

How Does It Work?

WBT uses cognitive restructuring, assertiveness training, problem solving, and scheduled assignments to enhance levels of psychological wellbeing across the six dimensions proposed in Ryff’s model, to bring clients from an impaired functioning to optimal (Fava & Ruini, 2003).

It is worth noting that optimal functioning is considered as balanced wellbeing, and how this is defined will vary depending on each person’s perspective, individual traits, social context, and cultural background.

Fava and Guidi (2020) propose that the evaluation of positive emotions and thoughts should occur within an integrative framework, looking at each of these dimensions of psychological wellbeing as a bipolar continuum where a balanced level is the target.

These six dimensions were theoretically defined in Ryff’s seminal article in 1989, with Fava and Ruini providing an operationalization of optimal and impaired levels in their 2003 article. In this section, we explore each dimension as originally conceptualized by Ryff and then in relation to decreases and excesses addressed through WBT.

1. Environmental mastery

Environmental mastery is defined as the ability to choose or develop environments that match one’s skills, talents, and conditions, having a sense of competence and mastery (Ryff, 1989).

When impaired, clients might feel like they lack a sense of control and are not able to pursue opportunities in their environment, leading to feelings of regret and rumination (Fava & Ruini, 2003). Excessive levels in this domain can be expressed as the person seeking complex or demanding challenges and not being able to enjoy downtime (Fava & Guidi, 2020).

2. Personal growth

Personal growth refers to being able to develop and grow as a person according to one’s own potential (Ryff, 1989). Impairment in this dimension can be reflected in difficulties transferring successful experiences from the past or a particular context to apply them in the future or a different scenario (Fava & Ruini, 2003).

Unhealthy high levels on this dimension are represented by setting unrealistic goals and high expectations that collide with the client’s reality (Fava & Guidi, 2020).

3. Purpose in life

Purpose in life is viewed as just that: the individual’s perception of having a purpose and meaning in life and experiencing a sense of direction (Ryff, 1989). Deficiencies in this dimension are expressed as perceiving a lack of purpose and direction, along with a devaluation of the client’s role in their own and others’ lives (Fava & Ruini, 2003).

Excess in this dimension is represented by being constantly dissatisfied with one’s performance due to setting unrealistic expectations and not being able to take responsibility for failures (Fava & Guidi, 2020).

4. Autonomy

Autonomy can be seen as the ability to be independent and turning inward to motivate and regulate one’s behavior (Ryff, 1989). Low levels of autonomy can be enacted as pleasing behaviors, hiding personal preferences, and placing others’ needs before their own (Fava & Ruini, 2003).

High levels of autonomy can be expressed when not being able to work with and learn from others, seek support, or establish positive relationships (Fava & Guidi, 2020).

5. Self-acceptance

Self-acceptance can be understood as having a positive attitude toward oneself and accepting positive and negative qualities (Ryff, 1989).

The lack of self-acceptance can be seen in clients holding unrealistic expectations and extremely high standards for themselves and engaging in perfectionistic attitudes and behaviors. This dissatisfaction neutralizes any episode of wellbeing (Fava & Ruini, 2003).

Excess of self-acceptance can be seen when clients have trouble taking responsibility for their own mistakes and blaming others (Fava & Guidi, 2020).

6. Positive relationships

A positive relationship with others is defined as the ability to have warm, caring, trusting, and satisfying relationships with other people and being able to experience empathy and reciprocity (Ryff, 1989).

Impairments in this dimension may be related to deeply held beliefs about oneself and others that hinder trust and openness (Fava & Ruini, 2003). Excessively high levels of positive relationships might take the shape of sacrificing personal needs for others, feeling worthless, and being overly forgiving (Fava & Guidi, 2020).

Applying the six dimensions in therapy

The role of the therapist is to assist the client in transitioning from impaired or excessive levels on each dimension of wellbeing to a more balanced functioning. Growth and improvements may come from discovering untested assumptions or from consistent work on specific areas identified jointly with the client.

Although WBT uses CBT techniques, they are not the same. According to Fava and Guidi (2020), the main differences between WBT and CBT are around their focus, aim, and approach.

From hedonia and eudaimonia toward euthymia

WBT ultimately aims at achieving a state of euthymia, a concept proposed by Marie Jahoda in the 1950s as a key criterion of optimal psychological functioning (Jahoda, 1958). Euthymia can be defined as the combination of flexibility, consistency, and resilience (Fava, 2016; Fava & Guidi, 2020).

This concept entails the ability to effectively adjust and balance the different dimensions of psychological wellbeing to the fluctuating demands of each individual and their context (Fava, 2016).

Traditionally, wellbeing has been conceptualized as either hedonic or eudaimonic, where hedonic is about increasing pleasure and avoiding pain, and eudaimonic is about finding meaning and personal growth. Fava and Guidi (2020) argue that in a clinical setting, these two standpoints are intertwined and that eudaimonia tends to disregard the balance between positive and negative emotions in psychological disorders.

WBT proposes euthymia as an integrative framework for improving psychological wellbeing, where balance is key.

Euthymia is characterized by three main elements (Bech, 2015):

1. The absence of mood disorders. Emotions such as anxiety, sadness, and irritability may be experienced, but they are bound to specific events, tend to be brief, and do not disrupt daily life.
2. The presence of a range of positive emotions, including high intensity (e.g., cheerfulness) and low intensity (e.g., calmness).
3. The presence of psychological wellbeing, comprised of flexibility, consistency, and resilience.

The mechanisms of WBT

Although the mechanisms of WBT are not clear yet, the effectiveness of WBT might be explained by the following factors:

1. The protective role of wellbeing on mental health.
   It has been estimated that psychological wellbeing can protect people from acute and chronic stress (Ryff & Singer, 1996, 2000; Fava & Ruini, 2003).
2. The balance of positive and negative emotions.
   Research findings suggest that negative emotions and positive affect are inversely correlated, which might explain why an increase in psychological wellbeing could reduce residual symptoms and why other forms of therapy do not (Rafanelli et al., 2000; Fava & Ruini, 2003).
3. Neurophysiological substrates of wellbeing.
   Research shows that positive and negative affect activate different brain regions, suggesting that the neural correlates of WBT may be different from those related to CBT (Rafanelli et al., 2000; Singer, Friedman, Seeman, Fava, & Ryff, 2005).

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3 Clinical Applications

WBT has been applied in a diversity of clinical settings to address a range of disorders with great efficacy, including mood disorders, anxiety disorders, body image disorders, and post-traumatic stress disorder (Fava & Guidi, 2020; Fava & Ruini, 2003; Ruini & Fava, 2012).

It is advised that the application of WBT follows clinical judgment to assess each case as a whole, considering their interacting elements (macro-analysis) and staging the interventions according to the nature of the clients’ conditions, as acute disorders should be first treated from a traditional approach rather than starting with WBT (Fava & Guidi, 2020).

Here, we detail three well-documented clinical applications of WBT.

1. Prevention of relapse

Several randomized controlled trials have used sequential modeling (Bockting et al., 2018; Farb et al., 2018; Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998; Fava et al., 2004; Kennard et al., 2014; Stangier et al., 2013), which is a particularly useful approach when assessing the effectiveness and distinct contribution of a treatment for a broadened recovery (Fava & Guidi, 2020).

The studies specifically applied WBT components after CBT, demonstrating the effectiveness of WBT in preventing relapse in depression.

2. Improvement of recovery

Most studies examining recovery rates within WBT have been centered on mood and anxiety disorders. A randomized controlled trial applied either CBT or WBT to treat residual symptoms after regular treatment, showing significant benefits including improvements in psychological wellbeing (Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998).

Another randomized controlled trial in generalized anxiety disorder supports these findings, where it was found that a sequential treatment of CBT and WBT had a higher impact on improving psychological wellbeing and reducing symptomatology (Fava et al., 2005).

3. Mood regulation

A randomized controlled trial in cyclothymia (i.e., mild to moderate mood fluctuations) applied the combination of CBT and WBT to compare it with treatment as usual.

Findings suggest that WBT in combination with CBT can effectively target both ends of the mood spectrum and produce lasting benefits, after one to two years of finishing therapy (Fava, Rafanelli, Tomba, Guidi, & Grandi, 2011).

Further research

According to Fava & Guidi (2020), additional case studies have been documented but need further exploration. Based on these studies, areas of future applications may include:

• Resistance to treatment, particularly in clients with depression, panic disorder, or anorexia nervosa
• Suicidal behavior, by mainly working on the dimension of meaning and purpose in life
• Withdrawal symptoms after psychotropic drug treatment
• Facilitating post-traumatic growth in clients experiencing post-traumatic stress disorder
• Improving health outcomes for patients experiencing chronic illness, such as cancer and chronic pain

A Guide and Treatment Manual

The original WBT protocol was developed in 1999 and was modified in 2009, leading to the publication of a treatment manual in 2016 (Fava, 2016).

The treatment sessions can be divided into three stages:

Initial sessions

This phase usually encompasses two sessions, but it may vary depending on each case and factors such as client compliance and resistance. These initial sessions aim to identify and explore wellbeing episodes and their situational context.

Clients are encouraged to keep a record of the circumstances accompanying the episodes of wellbeing and rate them on a 0–100 scale, with 100 being the highest level of wellbeing ever experienced by the client (Fava, 2016).

A common barrier to these initial sessions is clients’ concerns about not being able to complete the journal due to feeling unable to experience wellbeing. The role of the therapist here is to acknowledge this concern and noting that these moments are very likely to exist but often go unnoticed because of our negativity bias (Fava, 2016).

Intermediate sessions

This stage begins after the wellbeing experiences have been successfully identified, extending over a period of three sessions, depending on each client’s needs. These sessions use a similar approach as Rational-Emotive Therapy (Ellis, 1973), seeking and challenging irrational and automatic thoughts that create distress.

In WBT, clients are encouraged to bring awareness to their thoughts and beliefs that might hinder or interrupt their wellbeing (Fava, 2016).

This stage is regarded as an essential step, as it enables the psychotherapist to identify the areas of psychological wellbeing that are functioning well and those that are invaded by irrational and automatic thoughts.

The main role of the therapist here is to challenge those beliefs with questions such as “what is the evidence supporting this idea?” as well as to promote and reinforce activities that may evoke wellbeing, such as taking a walk in the park.

The role of the client is an active one, continuing with self-monitoring their wellbeing and beliefs (Fava, 2016).

Final sessions

The remaining sessions are particularly focused on each of the six dimensions of psychological wellbeing following Ryff’s model. These dimensions can be assessed and considered in each session through a conversational approach based on the client’s diary. It should be complemented by using the scales of psychological wellbeing (Ryff, 2014).

In these last sessions, the clients are gradually introduced to each dimension of wellbeing in a way that is linked to their recorded experiences. In addition to identifying irrational thoughts, the therapist assists clients to also notice alternative interpretations to situations perceived as blocking wellbeing (Fava, 2016).

5 WBT interventions

Fava (2016) distinguishes five wellbeing interventions that are comprised in WBT. These are sequential, with each building upon the previous one.

1. Psychological wellbeing journal

Clients use a structured diary to self-inquire about wellbeing events they have experienced and analyze the contextual factors surrounding the experience. They are asked to use a 0–100 scale to rate their wellbeing experience, with 100 being the highest score.

Clients also are encouraged to draw their attention to optimal wellbeing experiences, such as experiencing high environmental mastery in regards to a challenge, enjoyment, and flow.

2. Searching for automatic thoughts

The therapist encourages the client to take note of irrational and automatic thoughts and beliefs that lead to the interruption of experiencing wellbeing. The element for self-inquiry is wellbeing as opposed to distress in the case of CBT.

3. Behavioral exposure

The client is encouraged by the therapist to engage in activities that can evoke optimal experiences of psychological wellbeing. The therapist might break down the exposure into smaller and less challenging situations to facilitate the client’s engagement with these optimal experiences that they have been avoiding.

4. Wellbeing cognitive restructuring

By monitoring the records of wellbeing episodes, the therapist can assess each psychological wellbeing dimension in terms of impairments or overuse. One example of impairment could be having an external locus of control and lacking autonomy. An example of excessive development of one dimension could be compulsively trying out new experiences.

At this stage, the client can identify episodes of wellbeing and their interruptions, as well as deploy cognitive behavioral techniques to overcome those interruptions and attain optimal functioning.

5. Finding balance and individualization

Contrary to other positive psychology interventions, WBT seeks an optimal yet balanced functioning, in line with the concept of euthymia. This means that clients are not encouraged to score the highest levels of wellbeing, but rather to tune into the specific situation and their internal states and needs.

This acknowledges people’s diversity in terms of traits and cultural and social background when searching for their own balance.

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A Take-Home Message

WBT offers a novel approach to conceptualize wellbeing and implement psychotherapy using tools that may enable clients to realize and achieve their full potential in a balanced way.

Although empirical evidence strongly supports the applications of WBT in different settings and for a range of conditions, more research is needed to consolidate and expand its contributions to a wider range of populations.

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