Session

This session focuses on enhancing the patient's ability to self-monitor periods of well-being, primarily by review of homework, but it can also occur through observing the patient's well-being during the session. If the therapist notices a positive change in affect, the patient is asked to describe what is happening cognitively. This session also marks the beginning of the process of identifying thoughts and beliefs that lead to premature interruption of well-being.

GOALS

Review of the Patient's Well-Being through the Assessment Diary. The patient presents data collected in his/her Well-Being Diary. Any difficulty the patient reports in completing this homework is discussed. As we mentioned earlier, some patients may report difficulty in identifying any periods of well-being. For such patients, strong emphasis must be placed on continuing to use the diary. These patients are typically described as having low hedonic capacity and need additional practice in identifying feelings of well-being. When working with such patients it is again helpful to look for the patient's moments of well-being that occur in session. The therapist may choose to evoke such feelings using praise, reviewing times of past success, or similar techniques. When a moment of well-being occurs in the session, it is critical to highlight this for the patient and encourage him/her to do the same outside of session using the Well-Being Diary. Some attention is paid to the ratings assigned by the patient to moments of well-being. If the ratings are consistently low (e.g., 30), the therapist asks the patient to describe what would potentially represent a rating of 70 or 80. This is done to avoid having the patient focus exclusively on lower levels ofhedonia. The therapist comments on how the well-being instances reported in the assessment diary relate to Ryff's psychological dimensions of well-being (Ryff & Singer, 1996). These six dimensions of psychological well-being are summarized in Table 5.1.

Review of the Psychological Well-Being Scales. The therapist reviews with the patient the Psychological Well-Being Scales in case these have been administered in the previous session.

TABLE 5.1. Modification of the Six Dimensions of Psychological Well-Being

Dimensions Impaired level

Optimal level

Environ- The patient has difficulties in mental managing everyday affairs; feels mastery unable to change or improve surrounding context; is unaware of surrounding opportunities; lacks sense of control over external world.

Personal The patient has a sense of personal growth stagnation; lacks sense of improvement or expansion over time; feels bored and uninterested with life; feels unable to develop new attitudes or behaviors.

The patient has a sense of mastery and competence in managing the environment; controls external activities; makes effective use of surrounding opportunities; is able to create or choose contexts suitable to personal needs and values.

The patient has a feeling of continued development; sees self as growing and expanding; is open to new experiences; has sense of realizing own potential; sees improvement in self and behavior over time.

Purpose in life

Autonomy

Self-

acceptance

The patient lacks a sense of meaning in life; has few goals or aims, lacks sense of direction, does not see purpose in past life; has no outlooks or beliefs that give life meaning.

The patient is overconcerned with the expectations and evaluation of others; relies on judgment of others to make important decisions; conforms to social pressures to think or act in certain ways.

The patient feels dissatisfied with self; is disappointed with what has occurred in past life; is troubled about certain personal qualities; wishes to be different than what he/ she is.

The patient has goals in life and a sense of directedness; feels there is meaning to present and past life; holds beliefs that give life purpose; has aims and objectives for living.

The patient is self-determining and independent; is able to resist social pressures; regulates behavior from within; evaluates self by personal standards.

The patient has a positive attitude toward the self; accepts his/her good and bad qualities; feels positive about past life.

Positive The patient has few close, trusting relations relationships with others; finds it with others difficult to be open, and is isolated and frustrated in interpersonal relationships; is not willing to make compromises to sustain important ties with others.

The patient has warm and trusting relationships with others; is concerned about the welfare of others; is capable of strong empathy, affection, and intimacy; understands give and take of human relationships.

Note. Data from Ryff (1989).

Interruption of Well-Being. A critical step in WBT is to uncover thoughts and beliefs that lead to premature interruption of positive feelings. This can be accomplished by extending the use of the Well-Being Diary and by having the patient focus on the duration of feelings of well-being and the cognitions associated with an interruption in these feelings. An example would be receiving praise from a work supervisor and experiencing subsequent feelings of well-being, only to be interrupted by the thought, "He gives praise to everybody" or "He only wants me to stay late tonight." This is a perfect opportunity for the therapist to use the aforementioned CT techniques to intervene. At this point in therapy, the patient will have practiced these techniques on his/her own; thus, the therapist need supply only simple reinforcement and/or refinement of an existing skill set.

Homework Assignment. The patient is asked to continue use of the well-being assessment diary, with the additional instruction to look for interruptions of well-being. When a patient notices such an interruption as it occurs, he/she is encouraged to use previously learned CT techniques. The therapist also encourages the patient to engage in pleasurable activities on a regular basis (i.e., schedule a daily time to engage in a specific pleasurable activity). This increases the amount of time the patient spends in a well-being state, while offering more opportunities to self-monitor the interruption of well-being.

The similarities with the search for irrational, tension-evoking thoughts in Ellis and Becker's (1982) rational-emotive therapy and automatic thoughts in CT (Beck et al., 1979) are obvious. The trigger for self-observation is, however, different; it is based on well-being rather than distress.

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