Raj Persaud on well-being therapy

'After his third recurrent episode of major depression, a patient began to understand how his lack of autonomy led work colleagues to take advantage by making unreasonable demands.'

Well-being therapy goes beyond the alleviation of severe mental illness symptoms to the improvement of overall mental health. It analyses changes most helpful for people who want to improve everyday well-being.

Giovanni Fava and Chiara Ruini, of Italy's Bologna University and the US State University of New York, are pioneers of it. Almost every intervention they suggest is an exercise in improvement of personal power.

In a paper in the Journal of Behavior Therapy and Experimental Psychiatry, Fava and Ruini observe a frequent pattern in patients where a perceived lack of self-worth leads to unassertive behaviour. These patients tend to hide their opinions or preferences and put their needs behind others.

This leads to an impaired sense of mastery over the environment (Fava and Ruini believe a sense of 'environmental mastery' is key to mental well-being). If you don't feel in control of what happens to you at work or home, it will impair your sense of purpose in life.

They give an excellent example. After his third recurrent episode of major depression, a patient began to understand how his lack of autonomy led work colleagues to take advantage by making unreasonable demands. This resulted in an overwhelming workload that undermined his environmental mastery and became in itself a stress.

Fava and Ruini prescribe assertiveness training, which involves learning to say no. At first, this leads to more distress because you are courting disapproval. If you feel bad about yourself, then others hating you is worse. You bought their approval by obeying. Now that you are no longer their doormat, they will put emotional pressure on you to revert back.

The reported comment from the patient in his last session shows what happens if you persist in being more assertive: 'Now my workmates say that I am changed and have become a bastard. In a way I am sorry, since I always tried to be helpful and kind to people. But in another way I am happy, because this means that - for the first time in my life - I have been able to protect myself.'

Dr Raj Persaud is a consultant psychiatrist at South London and Maudsley trust and Gresham professor for public understanding of psychiatry