Euthymic suffering and wisdom psychology
Authors: Michael Linden
Journal: World Psychiatry (2020)

In Fava and Guidi's paper1, euthymia is defined by "lack of mood disturbances that can be subsumed under diagnostic rubrics" , "positive affects" and "psychological well-being" . So, good mood is euthymic. But, what about bad mood and suffering which can also not be subsumed under diagnostic rubrics? Life is no rose garden. All human beings experience illness, failure, conflicts with others, problems with children or spouse, financial troubles, or legal disputes. It would be a mental disturbance to feel happy under these circumstances. Is euthymia limited to positive affects or happy hours, or should it include all forms of "normal" mood? That not all hardship and negative feelings automatically qualify as disorder is confirmed by the ICD-10, which provides separate codes (Z codes) for negative life situations such as loss of work, social exclusion, or burnout. If people feel unhappy when burdened by negative life events, this is no mental disorder, but "healthy suffering" . It is of great importance not to medicalize such everyday problems2. In clinical practice, there are many people who contact medical experts because of healthy suffering. They need a professional evaluation together with some advice. We need diagnostic criteria for healthy bad mood. Such criteria include situational adequacy of the type and intensity of the emotional reaction, self-appraisal, controllability, compliance with individual and social norms, lack of specific psychopathological signs and symptoms3. Healthy persons with normal bad mood display consistency in their behavior and values, show environmental mastery, self-acceptance, positive relations with others, flexibility, and resilience to go on with daily duties4. So, healthy suffering and bad mood should be included in the concept of euthymia. How can interventions deal with such a broadened concept of euthymia? There are basically four different approaches to foster euthymia. The first one is to get rid of bad mood by improving well-being through the increase of pleasant activities and experiences5. "Regeneration therapy"6 engages people in positive and self-care exercises, from board games to cultural and social activities, relaxation and make oneself up. Positive effects of these interventions were shown in regard to depressed mood or distress intolerance and the ability to work. The bottom line is that, if you are under stress, you should do something positive for yourself or coddle yourself. The second approach also aims to counteract bad mood, this time by teaching how to generate positive emotions directly. "Euthymia therapy"7 teaches the art of enjoyment and experiencing of pleasures. "Well-being therapy"1 teaches people to focus on constituents of positive mood by self-observation, change of dysfunctional cognitions, and promotion of activities. Studies on these interventions showed positive effects in depressed or psychosomatic patients transdiagnostically. The bottom line is to improve the capacity of the individual to generate positive emotions. A different type of approach is represented by "mindfulness and acceptance" based therapies8. Their primary goal is not to get rid of negative emotions and cognitions, but instead to change the individuals' relationship to their emotional state, their experiences, and the living context. This is done by encouraging awareness and acceptance of unpleasant feelings through mindfulness practice and cognitive defusion. Commitment and behavior change processes are based on contact with the present moment. Bad mood is accepted and may still be present after treatment. This approach implicitly has a broader concept of euthymia, including bad and positive mood alike. The bottom line is to accept and arrange oneself with something that cannot be changed. Another approach, which goes in the same direction, is "wisdom therapy"9. Life span psychology describes wisdom as a psychological capacity, given to all persons, which is essential in coping with severe, irreversible or unsolvable problems, but also in dealing with daily dilemmas, such as the decision whether to stay at home with a sick child or to go to work. Similar to other psychological capacities, there are about a dozen sub-dimensions, such as recognition of reality (factual and procedural knowledge, contextualism, relativization of problems and aspirations), mastery of emotions (perception and acceptance of emotions, serenity), acceptance of personal limitations (self-relativization, self-distance), clarification and self-assurance of goals and values (value relativism, forgiveness and acceptance of the past, uncertainty tolerance, long-term perspective), and interactional competencies (change of perspective, empathy). "Wisdom therapy" provides strategies to translate these sub-dimensions into treatment. There is evidence that it works in patients with severe adjustment disorders9. The goal of the intervention is to learn how to deal with bad and good times alike. Euthymia can be defined as a state of wisdom, in which persons feel at ease with themselves and the world, their past, the present and the future, in good and bad times, and do not lose heart and courage in the face of adversities and hardship. The concept of euthymia should reflect the daily existence of human beings. Happiness is limited to very few moments in life. Demands, hardship, burdens fill the rest of time. Back pain, heavy work or driving a car in combusted streets do not produce happiness. But there is nevertheless euthymia. The problem of mental illness is that people are overburdened and impaired by daily hassles, while healthy persons have resilience and can deal with bad times. We should not create the misunderstanding that happiness is the goal to be pursued by our interventions. This can lead to disappointment. Instead, mastery of exceptional and daily burdens and demands, and how nevertheless to "feel OK" (not happy but euthymic), should be the aim.