Well-being therapy

1. Introduction

Version followed: the eight-session program in Fava's Well-Being Therapy: Treatment Manual and Clinical Applications (Karger, 2016), reconstructed from its published table of contents and a chapter-by-chapter review, cross-checked against Fava's own teaching slides (MGH Academy) and an eight-session trial protocol (chronic migraine RCT, Trials 2018), which orders the six dimensions differently (noted where relevant). The manual text itself is not drawn on here [uncertain: details below are from secondary descriptions of the manual unless stated].

Well-being therapy (WBT) is a short-term, structured, manualised psychotherapy developed by Giovanni A. Fava and colleagues at the University of Bologna in the 1990s, originally for residual symptoms and relapse prevention in mood and anxiety disorders after acute treatment. It is based on Carol Ryff's six-dimension model of psychological well-being (environmental mastery, personal growth, purpose in life, autonomy, self-acceptance, positive relations), which builds on Jahoda's 1958 positive mental health criteria [source: Karger PPS 1999 abstract; Ruini & Fava 2013; esanum].

Core idea of change: CBT starts from distress and its automatic thoughts; WBT starts from episodes of well-being and asks what thoughts and behaviours cut them short. By self-observing well-being in a structured diary, learning to notice and challenge the thoughts that interrupt it, and rebalancing the six dimensions, the patient "progressively learns how to make it grow" [source: Karger book page; MGH slides]. The target is not maximal positivity but balanced functioning, a state Fava calls euthymia (absence of mood disturbance, positive affect, and flexible, resilient psychological well-being) [source: MGH slides; Wikipedia Euthymia (medicine), citing Fava & Bech 2016 and Fava & Guidi 2020]. Fava presents WBT not as a stand-alone first-line therapy but as an integrative strategy usually sequenced after pharmacotherapy and/or CBT [source: esanum; IJMR review].

2. Framework

Format. Individual, structured, problem-oriented, 8–16 sessions (fewer if WBT follows CBT); in trials 8–12 sessions, weekly or every other week, 30–50 minutes each [source: MGH slides; esanum; Ruini & Fava 2013]. A four-session WBT exists for patients who have completed CBT (manual ch. 13; contents not drawn on) [uncertain]. Group formats and school/child adaptations exist (manual ch. 19) but are not drawn on here [uncertain]; one US group adaptation for people with physical disabilities runs eight 60-minute group sessions, one per dimension [source: National Register webinar; secondary adaptation, not Fava's protocol].

Three phases [source: MGH slides; esanum]:

Phase	Sessions (8-session manual)	Goal	Main tools
Initial	Assessment + sessions 1–2	Identify and record episodes of well-being and their context; notice optimal experiences	Clinimetric assessment, well-being check, structured diary, mastery/pleasure tasks
Intermediate	Sessions 3–4/5	Identify thoughts and behaviours that prematurely interrupt well-being	Diary with interrupting-thoughts and observer columns, cognitive restructuring
Final	Sessions 4/5–8	Discuss and modify beliefs and behaviours according to the six dimensions; consolidate and end	Dimension psychoeducation, profile of impaired/balanced/excessive levels, behavioural homework, termination and relapse planning

Session-by-session (2016 manual, as reviewed) [source: IJMR review]:

Initial evaluation: macroanalysis of problem areas; stress, symptoms, well-being, social support.
Session 1: history of distress, illness consequences and treatment; WBT rationale (build on positives, remove what blocks full development); well-being check; start the diary.
Session 2: review functioning and well-being check; discuss positive feelings alongside mental pain; introduce optimal (flow) experiences; therapist's written "our notes" with a behavioural prescription.
Session 3: review homework; self-observation triggered by well-being, not distress; interrupting thoughts and images; add observer column; perspective-taking.
Session 4: diary review; cognitive errors; begin restructuring; environmental mastery and personal growth.
Session 5: review use of observer alternatives; autonomy and purpose in life; CBT techniques for automatic thoughts and avoidance.
Session 6: review strategies for optimal functioning and restructuring; self-acceptance and positive relations.
Session 7: profile of the six dimensions (impaired, balanced, excessive) using diary examples.
Session 8: termination feelings, fear of relapse, medication tapering progress; re-administer symptom checklist and well-being check; offer phone contact and booster sessions.

Variant order. The migraine RCT protocol introduces autonomy (s4), environmental mastery (s5), positive relations + personal growth (s6), self-acceptance + purpose in life (s7), with daily pleasurable activities as homework from session 4 [source: Trials 2018 table]. Fava's own guidance is that the order follows the case formulation [source: MGH slides] — so choose order by which dimensions are most impaired or excessive [synthesis].

Sequential combination. Typical sequence: pharmacotherapy (or exposure/CBT) for the acute phase, then CBT for residual symptoms, then WBT, often while medication is tapered; e.g. 4 CBT + 4 WBT sessions in GAD; 12 weekly CBT/WBT sessions plus lifestyle suggestions after acute coronary syndrome (TREATED-ACS) [source: MGH slides; cris.unibo GAD record; Karger PPS 2020 abstract].

Criteria for moving on (the sources give phases but no formal criteria) [synthesis]:

Initial to intermediate: the patient reliably records several well-being episodes a week with context and intensity ratings.
Intermediate to final: the patient can name typical interrupting thoughts/behaviours and has begun writing observer alternatives.
To termination: a dimension profile is agreed, the patient applies restructuring on their own, and repeated assessment shows residual symptoms reduced and well-being improved [source for repeated assessment: MGH slides; IJMR review].

3. Guiding principles

[source: MGH slides; Ruini & Fava 2013; esanum; IJMR review; practical meanings are synthesis]

Start from well-being, not distress. Self-observation is triggered by good moments; practically, every diary review opens with what went well before what interrupted it.
Balance, not maximisation. Each dimension can be impaired or excessive; aim for the balanced middle, sometimes lowering a dimension (e.g. relentless purpose, over-giving).
Euthymia as the target. Treatment is judged by positive affect and flexible well-being as well as symptom absence; measure both.
Clinimetrics and repeated assessment. Assess with interview and self-ratings at intake and end, and re-stage as symptoms change; new problems surface as old ones remit.
Macroanalysis and staging drive sequencing. Map how problems link and treat the one that drives others first; WBT usually comes after acute symptoms are treated.
Individualised, case-formulation-led. Dimension order and emphasis follow the patient's profile, not a fixed script.
Integrative, add-on stance. WBT can borrow CBT (and other) techniques when indicated; it is not a stand-alone first-line treatment.
Structured, problem-oriented, homework-based. Every session ends with a written assignment; the diary is the engine of change.
Self-therapy. The patient learns to run the process without the therapist; build toward independent diary use and restructuring [source: IJMR review mentions self-therapy concept].
There are always some good moments. Even depressed patients have brief episodes of well-being to find; treat "nothing good happened" as a search problem, not a fact [source: esanum].
Therapist as appreciative, active coach. Written notes reinforce positive entries; the therapist is directive about tasks but works from the patient's own experiences [source: IJMR review; synthesis].

4. Intervention inventory

Coverage: every technique named in the sources (Fava slides, manual review, Ruini & Fava 2013, migraine protocol). Steps are written in my own words; the manual's own forms and wording are not reproduced. Example language is illustrative unless quoted.

4.1 Clinimetric initial evaluation and macroanalysis

Purpose / when: Before session 1, to decide whether WBT is indicated now, what to treat first, and to set baselines [source: MGH slides; IJMR review].
Steps: (1) Interview for current and residual symptoms, stress, illness history and treatments, social support and well-being. (2) Draw a macroanalysis: list problem areas and arrows showing which drive which (e.g. depression → social avoidance → family friction). (3) Stage the illness (acute, residual, recurrent) and decide sequence: acute symptoms (medication, exposure, CBT) before WBT. (4) Take baseline self-ratings of symptoms and well-being (trials used Kellner's Symptom Questionnaire, Ryff's PWB scales and observer-rated scales such as Paykel's or the Clinical Interview for Depression) [source: cris.unibo GAD record; Ruini & Fava 2013]. (5) Plan to re-assess at the end and to re-stage as problems shift.
Example language (illustrative): "Let's map how these problems feed each other, so we pick the one that unlocks the rest."
Watch for: Active acute episode, severe rumination or obsessions (the manual's reviewer flags these as hard to treat with WBT) [source: IJMR review]; treat these first. Working: a shared written map and an agreed sequence.

4.2 Introducing the WBT rationale (session 1)

Purpose / when: Session 1, after gathering the history of distress and treatment [source: IJMR review].
Steps: (1) Summarise what previous treatment achieved and what remains. (2) Explain the two aims: build on what already works, and remove what stops well-being from developing. (3) Contrast with CBT: here we start from good moments and look at what interrupts them. (4) Explain the diary and that the patient will become their own therapist over time.
Example language (illustrative): "So far we've worked on what makes you feel bad. Now we'll study the moments you feel even a little better, and what cuts them short."
Watch for: Patient hearing this as "think positive" — clarify the aim is balance and observation, not forced optimism [synthesis].

4.3 Well-being check (session 1 and session 8)

Purpose / when: A brief self-report of well-being given at the start and end to track change [source: IJMR review].
Steps: Administer at session 1, review it in session 2 alongside general functioning, repeat at session 8 with a symptom checklist and compare. The instrument's items are in the manual and are not reproduced here [uncertain: content]; a licensed, published alternative is Ryff's PWB scales [source: Ruini & Fava 2013].
Watch for: Very low scores on one dimension or unusually high scores (possible excess, e.g. inflated self-acceptance in cyclothymia) [source: Ruini & Fava 2013].

4.4 Structured well-being diary

Purpose / when: The core tool, from session 1 to the end: trains attention to episodes of well-being and supplies material for every session [source: MGH slides; esanum; Trials 2018].
Steps: (1) Ask the patient to record, daily, each episode of well-being, however brief. (2) For each: the situation/circumstances and an intensity rating from 0 (none) to 100 (most intense) [source: Trials 2018]. (3) In session, review entries first, praising any entry and looking for patterns (which activities, people, times of day). (4) From session 3 add columns for interrupting thoughts/behaviours and the observer (4.8–4.9). Exact column layout of the manual's form not confirmed [uncertain].
Example language (illustrative): "Write down any moment you felt okay, even for a few minutes, where you were, and how strong it was from 0 to 100."
Watch for: Empty diaries — a common early objection (see 5.1) [source: esanum]. Working: more entries, more varied contexts, and the patient spontaneously noticing good moments.

4.5 Identifying optimal experiences (flow)

Purpose / when: Session 2; widens the search from pleasant moments to absorbed, challenging, competent activity ("optimal experiences") where the patient gets relief from mental pain [source: IJMR review; MGH slides; Trials 2018].
Steps: (1) Explain optimal experience: fully engaged, skills matched to challenge, time passing unnoticed. (2) Ask for past and current examples (work, hobbies, caring, sport). (3) Assign tracking of such episodes in the diary. (4) Use them later to plan activities and for environmental mastery and personal growth.
Example language (illustrative): "When did you last lose track of time doing something a bit demanding that you were good at?"
Watch for: Patients who only report passive pleasures; gently probe for mastery moments [synthesis].

4.6 Therapist's written notes ("our notes")

Purpose / when: From session 2: a written record of appreciative comments on positive diary entries, key session points and a behavioural prescription [source: IJMR review].
Steps: (1) Near the end of each session write (or co-write) 3–4 lines: what went well in the diary, the main learning point, the task for the week. (2) The patient keeps the notes with the diary and rereads them. (3) Start the next session by checking the prescription.
Example language (illustrative): "Note for this week: you rated Tuesday's walk with your sister at 60 — good. Task: one such walk on two more days."
Watch for: Notes becoming generic; anchor every comment to a specific entry [synthesis].

4.7 Mastery, pleasure and pleasurable-activity homework

Purpose / when: From the initial phase onward, to increase the frequency of well-being episodes [source: MGH slides ("mastery and pleasure tasks"); Ruini & Fava 2013 ("assignment of pleasurable activities"); Trials 2018 (daily pleasurable activities from session 4)].
Steps: (1) Pick activities from the diary that produced well-being or optimal experience. (2) Prescribe them concretely (what, when, how long), starting small. (3) Ask the patient to log the episode and its rating. (4) Review and adjust. Graded task assignment is commonly listed among WBT techniques in early papers not drawn on here [uncertain].
Example language (illustrative): "Since gardening scored 70, let's schedule twenty minutes on three mornings and see what the diary says."
Watch for: Perfectionist over-scheduling (excess environmental mastery) [synthesis from MGH slides].

4.8 Self-observation of interrupting thoughts, behaviours and images

Purpose / when: Session 3 onward (intermediate phase): find what prematurely ends well-being episodes [source: MGH slides; IJMR review; Trials 2018].
Steps: (1) In the diary review, take a high-rated episode and ask how it ended. (2) Identify the thought, image or behaviour that cut it short (e.g. "I don't deserve this", a mental picture of a coming problem, leaving early). (3) Add an interrupting-thoughts column next to each episode. (4) Look for repeating themes. Triggers for monitoring are well-being episodes, not distress, which distinguishes this from CBT [source: IJMR review]; automatic thoughts are explored as visual images as well as words [source: IJMR review].
Example language (illustrative): "You were enjoying the dinner at 70. What went through your mind right before it dropped?"
Watch for: Drift back to distress-focused thought records; keep the entry point on the positive episode.

4.9 The observer column and perspective-taking

Purpose / when: Session 3 onward; generates alternatives to interrupting thoughts by viewing the episode from outside [source: IJMR review].
Steps: (1) Add an observer column. (2) Ask the patient to imagine how a neutral or kind observer (or a specific person) would interpret the episode and the interrupting thought. (3) Write that alternative. (4) Next week, check whether the patient used the observer's alternative in the moment and whether the episode lasted longer [source: IJMR review session 5].
Example language (illustrative): "If a friend watched that moment, what would they say about the thought 'this won't last'?"
Watch for: Alternatives that are just reassurance; aim for realistic, balanced statements. Working: episodes last longer or recover faster after interruption.

4.10 Cognitive restructuring of well-being-interrupting beliefs

Purpose / when: Session 4 onward; address cognitive errors behind interruptions and, in the final phase, beliefs tied to specific dimensions [source: MGH slides; IJMR review; Ruini & Fava 2013].
Steps: (1) Name the cognitive error in the interrupting thought (e.g. all-or-nothing, discounting the positive, catastrophising). (2) Examine evidence and alternatives as in CBT. (3) Link the thought to a dimension (e.g. "I should be further along" → personal growth). (4) Design an in vivo test of the automatic thought as homework [source: Trials 2018 session 8]. (5) Record outcome in the diary.
Example language (illustrative): "The thought 'it's only good because I'm on holiday' discounts what you did. What's the evidence you contributed?"
Watch for: Restructuring becoming argument; keep it collaborative.

4.11 CBT techniques for residual avoidance

Purpose / when: When interruptions are maintained by avoidance (session 5 in the manual) [source: IJMR review], or when residual phobic avoidance remains (e.g. exposure for social phobia before WBT in Fava's staging example) [source: MGH slides].
Steps: Use standard graded exposure or behavioural experiments for the avoided situation, then log the resulting well-being episodes in the diary. For exposure: obtain informed consent, explain temporary anxiety increase, agree a graded hierarchy, and screen for contraindications (unstable medical conditions, active substance misuse, acute suicidality, untreated psychosis) [synthesis; standard CBT practice].
Example language (illustrative): "You've avoided the team lunch. Let's plan the first small step and record how you feel afterwards, good moments included."
Watch for: Overwhelm or new avoidance; slow the hierarchy.

4.12 Introducing a well-being dimension (general method)

Purpose / when: Final phase (sessions 4–7); the clinically modified Ryff model is "progressively introduced to patients" [source: Ruini & Fava 2013]. Each dimension can be impaired, balanced or excessive; the goal is the balanced level [source: MGH slides].
Steps: (1) Pick the dimension that best explains this patient's interruptions (manual order or case-led order, see section 2). (2) Explain it briefly with examples and metaphors [source: Trials 2018]. (3) Re-read diary entries in its light: which interruptions reflect a deficit or an excess here? (4) Restructure the linked beliefs (4.10). (5) Prescribe a behavioural task targeting it, plus continued daily pleasurable activity and diary [source: Trials 2018; Ruini & Fava 2013].
Watch for: Lecturing; keep the explanation short and tied to the patient's own entries [synthesis].

4.13 Environmental mastery

Purpose / when: The most frequent impairment in mood disorders [source: Ruini & Fava 2013]. Deficit: difficulty managing everyday affairs, feeling unable to change things, missing opportunities. Excess: cannot relax or savour, takes on too much, feels exploited and overwhelmed by requests [source: MGH slides; Ruini & Fava 2013].
Steps (deficit): (1) Use diary entries where the patient handled something well and ask what they did. (2) Restructure thoughts like "I can't cope" against that evidence. (3) Set small planning or problem-solving tasks with a clear first step. Problem-solving and planning as named WBT techniques come from earlier papers not drawn on [uncertain].
Steps (excess): (1) Identify where control-seeking crowds out enjoyment. (2) Prescribe deliberate unstructured time and savouring of a pleasant activity. (3) Practise declining one request.
Example language (illustrative): "Last week you sorted the bank problem in one call. What does that say about 'I can't manage anything'?"
Watch for: Working — more mastery entries; for excess, entries of relaxed enjoyment appear.

4.14 Personal growth

Purpose / when: Deficit: sense of stagnation, boredom, inability to see progress already made toward goals. Excess: future fixation with denial of past negative experiences, unrealistic standards, "benign illusions" [source: MGH slides; Ruini & Fava 2013].
Steps: (1) Ask the patient to compare now with a past point (e.g. start of treatment) using diary evidence. (2) Restructure thoughts that measure only the distance still to go. (3) Plan one new activity or learning step, building on optimal experiences (4.5). (4) For excess, help the patient acknowledge and process past setbacks rather than skipping over them.
Example language (illustrative): "You're focusing on how far you are from full recovery. What's different now compared with three months ago?"
Watch for: Working — the patient names progress unprompted.

4.15 Autonomy

Purpose / when: Deficit (common in social phobia and anxiety): over-reliance on others' judgements, conformity. Excess: constantly fighting for independence, unable to work in teams, learn from others or ask for help [source: MGH slides; Ruini & Fava 2013].
Steps: (1) Find diary episodes interrupted by worry about others' opinions. (2) Restructure ("they will think I'm stupid"). (3) Assign voicing an opinion or making a choice without seeking approval. Assertiveness training is often listed among WBT techniques in early papers not drawn on here [uncertain]. (4) For excess, assign asking for help or accepting input once in the week.
Example language (illustrative): "What would you have ordered if no one at the table were watching?"
Watch for: Fava and Ruini warn against aiming to turn an introverted, socially anxious person into a "totally independent" one — aim for the patient's balanced level [source: Ruini & Fava 2013].

4.16 Purpose in life

Purpose / when: Deficit: little sense of meaning or direction. Excess: obsessive passions, rigid attachment to unattainable goals, inability to admit failure [source: MGH slides; Ruini & Fava 2013].
Steps: (1) Use diary episodes to find what the patient values (activities rated high, optimal experiences). (2) Help set short- and medium-term goals linked to those values. (3) For excess, examine costs of rigid goals and explore flexible alternatives or letting a goal go.
Example language (illustrative): "Your highest ratings cluster around teaching your nephew. What would it look like to have more of that in your week?"
Watch for: Goals set by others or by guilt; check whose goal it is [synthesis].

4.17 Self-acceptance

Purpose / when: Deficit: chronic dissatisfaction with self and past, unrealistically high standards. Excess: inflated self-esteem, narcissism, difficulty admitting mistakes (seen in cyclothymia and bipolar disorder) [source: MGH slides; Ruini & Fava 2013]. The manual illustrates this dimension with social phobia [source: IJMR review].
Steps: (1) Identify self-critical interruptions ("I should have done better"). (2) Restructure standards and all-or-nothing self-evaluation. (3) Assign noting one thing done adequately each day. (4) For excess, use diary episodes to examine overlooked mistakes and others' feedback, aiming at realistic self-appraisal.
Example language (illustrative): "Would you hold a colleague to the standard you're using for yourself here?"
Watch for: In mood-swing patients, rising self-esteem may be early hypomania rather than progress — check mood symptoms [synthesis from Ruini & Fava 2013].

4.18 Positive relations with others

Purpose / when: Deficit: few close, trusting relationships, isolation, unwillingness to compromise. Excess: exaggerated empathy and self-sacrifice that risks burnout [source: MGH slides; Ruini & Fava 2013]. The manual illustrates this with couple relationships [source: IJMR review].
Steps: (1) Find diary episodes involving others (rated high or interrupted). (2) Restructure beliefs about trust, rejection or obligation. (3) Assign one contact-building action (deficit) or one boundary/self-care action (excess).
Example language (illustrative): "Your Sunday entries drop every time you cancel your own plans to help. What would one 'no' look like?"
Watch for: Working — more relational entries, fewer resentment-driven interruptions.

4.19 The six-dimension profile (session 7)

Purpose / when: Session 7: consolidate by building a profile of the patient's level on each dimension (impaired, balanced, excessive) using diary examples [source: IJMR review].
Steps: (1) Draw six rows. (2) For each, agree the current level with one diary example. (3) Mark improvements since the start. (4) Choose 1–2 dimensions to keep working on after therapy.
Example language (illustrative): "Where would you put yourself now on mastery — too little, about right, or too much? Which entry shows that?"
Watch for: Disagreement between your view and the patient's; explore rather than impose.

4.20 Termination and relapse prevention (session 8)

Purpose / when: Final session [source: IJMR review; Trials 2018].
Steps: (1) Place WBT in the patient's treatment history. (2) Discuss feelings about ending and fear of relapse; review progress during any medication tapering (tapering is managed by the prescriber). (3) Review efforts to counter interruptions; continue restructuring and in vivo testing. (4) Repeat the symptom checklist and well-being check and compare with baseline. (5) Agree availability for brief phone calls and booster sessions, and early-warning signs.
Example language (illustrative): "If the diary starts to empty again, that's your cue to call for a booster."
Watch for: Re-emerging symptoms on the final assessment — re-stage rather than simply end [synthesis from MGH slides].

4.21 Four-session WBT after CBT

Purpose / when: For patients who have already completed CBT (manual ch. 13); used in the GAD trial as 4 CBT + 4 WBT sessions [source: Karger book page; cris.unibo GAD record].
Steps: Session contents are not described in the sources [uncertain]. A reasonable compression is diary and optimal experiences (s1), interrupting thoughts and observer (s2), the 2–3 most relevant dimensions (s3), profile and ending (s4) [synthesis].

4.22 Sequential combination planning

Purpose / when: Deciding where WBT sits in a treatment course [source: MGH slides; Wikipedia Euthymia (medicine) citing Fava & Guidi 2020].
Steps: (1) Treat the acute episode (pharmacotherapy, exposure or CBT). (2) Re-assess residual symptoms. (3) Deliver CBT for residual symptoms, then WBT; in recurrent depression this may run while antidepressants are tapered by the prescriber. (4) Re-assess at the end and at follow-up.
Watch for: Starting WBT during an acute episode; the sources place it after acute response.

5. Handling problems

The sources address only the first problem directly; the rest is synthesis built on WBT's principles [synthesis unless tagged].

5.1 "Nothing good happens" / empty diary

Patients often object early that they feel unwell and the diary will stay empty; Fava's position is that brief moments of well-being always exist and need to be tracked down [source: esanum].
Response: lower the threshold (any moment rated even 10–20 counts, including relief or calm); reconstruct yesterday hour by hour in session and find one entry together; use set reminders (e.g. after meals) to check in; praise any entry in "our notes" [synthesis].

5.2 Patient keeps reporting distress instead

Acknowledge the distress briefly, note it, then return to the nearest positive episode and ask what interrupted it. If distress dominates every session, re-stage: residual symptoms may need more CBT or medical review before WBT [synthesis from MGH slides on staging].

5.3 Severe rumination, obsessions or a new acute episode

The manual's reviewer notes WBT may be hard to apply with severe depressive rumination or obsessions [source: IJMR review]. Pause WBT, treat the acute or obsessional problem (e.g. CBT, exposure and response prevention, medication review) and resume WBT later [synthesis]. Assess suicide risk with standard practice whenever mood worsens; WBT is not a crisis intervention [synthesis].

5.4 Non-adherence to homework

Explore the obstacle concretely (time, forgetting, hopelessness, perfectionism about writing it properly). Shrink the task (one entry a day), attach it to a routine, and start sessions by reviewing it so it clearly matters. Treat non-completion as diary material: what thought stopped you? [synthesis]

5.5 Resistance to "positivity"

Some patients hear WBT as being told to cheer up, or fear that noticing good moments will "jinx" them. Re-explain the balance model (excess is also a problem) and that the task is observation, not forced optimism. Fear of well-being is itself an interrupting thought to explore (4.8) [synthesis].

5.6 Overwhelm

Too many tasks or dimensions at once: drop back to diary plus one task; work one dimension per session or slower; for exposure components, step back down the hierarchy [synthesis].

5.7 Ruptures

Signs: patient feels criticised by restructuring, or feels the therapist dismisses their pain by focusing on positives. Name it, validate the pain (WBT sessions explicitly discuss mental pain alongside positive feelings [source: IJMR review]), invite feedback on pace and focus, and adjust [synthesis].

5.8 Modality-specific difficulties

Excess dimensions mistaken for health: high purpose, autonomy or self-acceptance scores may reflect rigidity or inflation; check the excessive pole before reinforcing [source: Ruini & Fava 2013; MGH slides].
Mood swings / cyclothymia: rising well-being may signal hypomania; monitor mood, and target excessive dimensions to restore balance [synthesis from Ruini & Fava 2013].
Medication tapering: coordinate with the prescriber; never advise on dosing; treat tapering-related fears as diary material [synthesis; IJMR review notes tapering is discussed in session 8].
Over-reliance on the therapist: emphasise self-therapy; by session 6–7 the patient should lead diary review [synthesis].
End-of-treatment worsening: offer booster sessions and phone contact as in the manual [source: IJMR review].

Sources

Sources: