The clinical role of psychological well-being

Historically, mental health research has been dramatically weighted on the side of psychological dysfunction, and health has been equated with the absence of illness, rather than the presence of wellness. Ryff and Singer 1 suggested that the absence of well-being creates conditions of vulnerability to possible future adversities and that the route to enduring recovery lies not exclusively in alleviating the negative, but also in engendering the positive. Bringing the person out of negative functioning is one form of success, but facilitating progression toward the restoration of positive functioning is quite another.

George Vaillant rightly points out to the relative contributions and cultural sensitivity of different models of positive mental health. However, the concept of mental health is inextricably linked to that of psychological well-being. A comprehensive model developed by C. Ryff 2 provides an integration of different viewpoints. It encompasses six inter-related psychological dimensions: positive evaluation of one’s self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage effectively one’s life, and a sense of self-determination.

A number of clinical studies have yielded substantial support to this model. Assessment of psychological well-being using the Psychological Well-Being Scales 2 has disclosed that these dimensions are often impaired in patients with mood and anxiety disorders who remitted upon standard pharmacological or psychotherapeutic treatment 3. Lack of psychological well-being has been found to be a risk factor for depression 4. A specific psychotherapeutic strategy for increasing psychological well-being and resilience, the well-being therapy (WBT), based on Ryff’s conceptual model 2, has been developed and tested in a number of randomized controlled trials 3. The application of WBT, in addition to standard cognitive behavior therapy (CBT), to patients with recurrent depression who responded to drug treatment was found to yield a significantly lower relapse rate at a 6-year follow-up compared to clinical management (CM) 5. Further, the sequential combination of CBT and WBT has been found to induce a higher degree of remission, as shown by both distress and well-being scales, compared to CBT alone in generalized anxiety disorder, with advantages persisting at a 2-year follow-up 6.

A recent randomized controlled trial in cyclothymia 7 has yielded additional insights. Sixty-two patients with DSM-IV cyclothymic disorder were randomly assigned to CBT/WBT or CM. At post-treatment, significant differences were found on all outcome measures, with greater improvements after treatment in the CBT/WBT group compared to the CM group. Therapeutic gains were maintained at 1- and 2-year follow-ups. These results imply that a sequential combination of CBT and WBT, addressing both polarities of mood swings and comorbid anxiety, yields significant and persistent benefits in cyclothymic disorder. This investigation suggests that it is the balance among the various psychological dimensions that matters the most.

Ryff and Singer 1 emphasize Aristotle’s admonishment to seek “what is intermediate”, avoiding excess and extremes. The pursuit of well-being may in fact be so solipsistic and individualistic to leave no room for human connection and the social good; or it can be so focused on responsibilities and duties outside the self that personal talents and capacities are neither recognized nor developed. Ryff and Singer 1 thus value the concept of balance, both as a theoretical guide and as an empirical reality that scholars of well-being need to appreciate.

The application of Ryff’s model 2, both in terms of assessment and treatment, thus suggests that optimally balanced well-being differs from person to person: there is no single right way to be well (people have differing combinations of strengths and vulnerabilities and one has to work with what is available). The cross-cultural implications of the model are thus considerable and should integrate Vaillant’s framework. Further, Ryff 2 emphasizes that personality assets should be combined with contextual variables (work, family life, social ties and socioeconomic conditions). The central message is that personality, well-being and distress come together in different ways for different people.

G. Engel 8 defined etiological factors as “factors which either place a burden on or limit the capacity of systems concerned with growth, development or adaptation”. Positive mental health should aim to address these etiological factors. Assessment of well-being and pursuit of well-being enhancing strategies such as WBT should be incorporated in clinical evaluation and therapeutic plans 9.