Innovations

Psychother Psychosom 2011;80:199205

DOI: 10.1159/000321580

Received: January 5, 2010

Accepted after revision: September 29, 2010
Published online: April 14, 2011

Treatment of Posttraumatic Embitterment

Disorder with Cognitive Behaviour Therapy Based
on Wisdom Psychology and Hedonia Strategies
MichaelLinden KaiBaumann BarbaraLieberei ConstanzeLorenz MaxRotter
Research Group Psychosomatic Rehabilitation at the Charit University Medicine Berlin, and Department of
Behavioural and Psychosomatic Medicine at the Rehabilitation Centre Seehof, Teltow/Berlin, Germany

Key Words
Posttraumatic embitterment disorder Adjustment
disorder Cognitive behaviour therapy Wisdom therapy
Hedonia therapy Psychotherapy outcome research
Randomized clinical trial Stress disorder Therapeutic
results Trauma Well-being therapy

Abstract
Background: Posttraumatic embitterment disorder (PTED)
is a reaction to unjust or humiliating life events, including
embitterment and impairment of mood, somatoform complaints, reduction in drive, withdrawal from social contacts,
and even suicide and murder suicide. Patients have been
shown to be nonresponders to many treatments. This paper
gives an outline of cognitive behaviour therapy based on
wisdom psychology and reports first data on treatment effects. Method: In a first pilot study on psychotherapy for
PTED, a cohort of 25 PTED inpatients was treated with routine multidimensional cognitive behaviour therapy. A second consecutive cohort of 28 patients was treated with
PTED-specific cognitive behaviour therapy, which is based
on wisdom psychology (wisdom psychotherapy) and another 29 patients with cognitive behaviour therapy based on
wisdom psychology together with additional hedonia strategies (wisdom and hedonia psychotherapy). Treatment integrity was measured with special modules of the Behaviour

2011 S. Karger AG, Basel

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Therapy Competency Checklist. The outcomes were measured in all 3 groups with the SCL-90 and a global clinical rating of patients and therapists on treatment outcome. Results: There were significant and clinically meaningful reductions in the SCL score after wisdom therapy, as compared
to routine treatment. In clinical ratings by therapists and patients, both specific treatments were judged as more effective than treatment as usual. Additional hedonia strategies
did not lead to better treatment effects. Conclusions: The
results of this pilot study suggest that wisdom psychology
offers an approach to treat PTED and justify further randomized controlled outcome studies.
Copyright 2011 S. Karger AG, Basel

Introduction

Negative life events, burdens of life, life-threatening

experiences, loss of loved ones or humiliating experiences can result in persistent psychological stress [110].
An example is posttraumatic embitterment disorder
(PTED) [1113], a severe and prolonged psychological reaction to normal, though not everyday events like job
loss, divorce or bereavement. The distressing event typically involves injustice and/or personal humiliation or insult. As a consequence, the person suffers from unwanted, repetitive memories of the event, i.e. intrusions, which
Prof. Dr. M. Linden
Research Group Psychosomatic Rehabilitation
Lichterfelder Allee 55
DE14513 Teltow/Berlin (Germany)
Tel. +49 3328 345 678, Fax +49 3328 345 555, E-Mail michael.linden@charite.de

are accompanied by mood impairment, emotional numbing, insomnia and hyperarousal. Affected individuals
avoid places or people associated with the critical event,
retreat from social encounters, are unable to work and
even harbour suicidal ideas and aggressive impulses towards others, including homicidal fantasies.
The treatment of reactive disorders in general and
PTED in particular can be difficult. Embitterment [14] is
characterized by feelings of hopelessness, fatalistic attitudes of the patients, rejection of help (The world will see
what it did to me) and an aggressive outward-turned expectation that the world must change but not the patient.
According to clinical experience, these patients can take
up disproportionately large amounts of time and effort
from clinicians and often turn out to be treatment resistant [12, 13]. Therefore, new treatment approaches are
needed. In reference to recent developments in wisdom
psychology [1520] and well-being psychology [2125], a
specific treatment approach was developed, based on
cognitive behaviour therapy combined with additional
wisdom and hedonia strategies [26, 27].
In recent years wisdom has received much scientific
attention in psychology. It can be defined as expertise
in coping with difficult or unsolvable life problems [15
20]. Wisdom can be understood as a psychological competency, similar to assertiveness or social competency,
which helps people to tolerate or cope with complex and
ambiguous life situations. Wisdom is a multidimensional psychological construct, including dimensions like
(1) change of perspective, (2) empathy, (3) perception and
acceptance of emotions, (4) emotional serenity, (5) factual knowledge, (6) procedural knowledge, (7) contextualism, (8) value relativism, (9) uncertainty acceptance,
(10) long-term perspective, (11) distance from oneself
and (12) reduction in level of aspiration. Wisdom can be
learned and taught, so the question is whether it can also
be a tool in psychotherapy [26, 27]. As patients with embitterment reactions have to cope with unsolvable life
problems, wisdom could possibly be a way out.
Hedonia can be defined as orientation to positive aspects in life and a focus on what can be enjoyed, while at
the same time trying to ignore or suppress thoughts about
what is burdensome. Lutz et al. [21, 22] have described
hedonia psychotherapy as a form of cognitive behaviour
therapy close to salutotherapy [23] or well-being therapy
[24, 25]. Elements of hedonia therapy are the concentration on self-care, social encounters, pleasant activities,
awareness of positive aspects in life and most of all
distraction from negative memories and thoughts. As patients with embitterment reactions tend to be locked up
200

Psychother Psychosom 2011;80:199205

in thoughts about what has happened and tend to neglect

all other areas of life, distraction, self-care and a focus on
positive aspects in life could possibly be of help.
This paper reports on a pilot study on wisdom-oriented cognitive behaviour therapy in PTED patients. In a
consecutive cohort-controlled design, treatment as usual
(TAU) was compared with wisdom-oriented cognitive
behaviour therapy (W) and with wisdom-oriented cognitive behaviour therapy plus hedonia therapy (WH). Patient allocation to W and WH was done by randomization.

Method
Patients and Setting
All patients fullfilled the published diagnostic criteria for
PTED according to a standardized diagnostic interview [28].
They were inpatients of a department of behavioural and psychosomatic medicine to which patients are referred at the initiative of
health or pension insurance after prolonged periods of sick leave
or when there is an impairment of the ability to work and early
retirement is seen as possible. Inpatient treatment lasts about 6
weeks. All patients get at least 2 individual cognitive behaviour
therapy sessions per week, 2 group cognitive behaviour therapy
sessions, 4 ergotherapy sessions, 4 sport therapy sessions, social
counselling and all needed forms of other medical treatment.
A first cohort of PTED patients received TAU by different physicians or clinical psychologists according to the above programme (TAU group, n = 25 of 29 patients who had fulfilled the
inclusion criteria). A second consecutive cohort of 86 PTED patients was asked to give their written informed consent for participation in a special treatment programme without receiving
information on the particular mode of treatment which was applied in their case. This was accepted by 57 patients. According to
random allocation, 28 patients were treated with cognitive behaviour therapy based on wisdom strategies (W group), and 29 with
cognitive behaviour therapy based on wisdom and hedonia strategies (WH group). As these patients were treated in an inpatient
setting for a short period of time and as treatment was part of their
regular treatment programme, no further dropouts occurred
once the patients had agreed to participate. All patients had 2 individual sessions and 2 group sessions per week for 6 weeks. Two
cognitive behaviour therapists (male, 45 years, state-licensed psychological psychotherapist; female, 37 years, physician, state-licensed specialist in psychosomatic medicine and psychotherapy),
who were specially trained in wisdom and hedonia strategies for
PTED, each applied both types of treatment.
The patients in all 3 groups were about 50 years of age, two
thirds female, mostly married, and two thirds with high school
education at maximum (table1). All patients showed prolonged
periods of sickness absence from work in the year before treatment.
Instruments
Diagnoses were made with the MINI (MINI, German version
4.4) [29], a standardized diagnostic psychiatric interview which

Linden/Baumann/Lieberei/Lorenz/Rotter

Table 1. Patient characteristics

TAU
W
WH
patients patients patients
(n = 25) (n = 28) (n = 29)

Age, years
Female, %
Married, %
Highest education high school, %
Sickness absence in the past year, weeks

48.7
60.0
77.6
70.3
37.9

48.8
67.9
46.4
71.4
25.5

51.9
62.1
58.6
62.1
20.5

included a special part on PTED [28]. Although PTED is still a

diagnostic concept under investigation, it can at present be classified according to ICD-10 in the category F 43.8 (special reaction
to severe stress). The present status of all patients before and after
treatment was assessed with the SCL-90 self-rating scale [30],
which is used on a routine basis in the hospital and reflects comprehensively the overall status of the patient, as it covers a large
range of symptoms.
At the end of treatment, the therapists were asked: Has the
treatment goal of the patient been reached?, Has the treatment
goal of the therapist been reached? and What is the degree of
global disability?. The patients were asked: Has your personal
treatment goal been reached?, Was the stay in this hospital in
general of help to you? and Did you like the stay in this hospital?.
Answers were given on visual analogue scales, ranging from 0 to
10 or from 0 to 100 for disability.
Treatments
Initial Steps in Cognitive Behaviour Therapy with PTED Patients. The first and difficult therapeutic task in the treatment of
PTED patients, independent of any specific treatment focus, is to
establish a working relationship between therapist and patient. As
these patients are distrustful and do not easily accept help, therapists have to convey with empathy and unconditional acceptance
that they appreciate the patients suffering, are clearly on the side
of the patient, understand that injustice has occurred and think
that justice should be brought about. The next step is to analyze
what the critical event and embitterment have done to the patient,
what the role of intrusive thoughts is and how these lead to bad
emotions. Avoidance behaviour is assessed, e.g. why patients no
longer go to particular shops or sometimes avoid full areas of the
city. It is analyzed with the patient how and why they retreat from
friends and even the family and no longer attend social or cultural events. The patient learns that he or she is not only punished
by the critical event but even more by the consequences of his or
her present mental status, which is a double punishment. The
question is whether the patient wants to allow the aggressor to
punish him or her twice, first by the critical event and then by
social withdrawal and a bad mood. With empathy and sympathy,
it is possible to communicate that the patient does not deserve this
and that he or she has suffered enough. A paradoxical intervention can be used. The aggressor is given a message or even punished by not allowing him or her to influence the patients life and
by showing that the patient can stand up.

Cognitive Behaviour Therapy in

Posttraumatic Embitterment Disorder

Wisdom Strategies. Cognitive behaviour therapy including

wisdom strategies followed a manual [26, 27]. The patient is
asked to report the details of what happened. Who did what, how
and when? The patient is encouraged to express his or her evaluations, feelings and emotions. The therapist summarizes socially unacceptable emotions of the patient as emotions which are
held by the therapist (If my wife did this, I could beat her. If I
hear what you say, thoughts of revenge come to my mind, I
would throw stones at his car). Patients are encouraged to accept the full blend of their emotions including unacceptable
ones (desire to kill somebody, humiliation, etc.). Such emotions
are also elicited and reflected by cognitive rehearsal. Patients are
challenged to build up a rivalry over the control of the patients
emotions between the patient and the offender. It is furthermore asked: What hurt most, what really made you mad? in
order to analyze the patients central motives, values and basic
beliefs, which have been violated. The next question is how one
can solve difficult problems in life as such, especially those
which cannot be undone. Of help are wisdom competencies
like factual knowledge and procedural knowledge about what
can be done and what not, change of perspective and empathy
in order to understand what made the other people act as they
did, perception and acceptance of emotions and emotional serenity, which help to keep a clear mind and not be overwhelmed
by ones own emotions, contextualism, value relativism and
long-term perspective, which put the negative event in a broader context of meaning and life development, uncertainty acceptance, which allows the person to act without knowing for sure
the outcome, distance from oneself and reduction of the level
of aspiration, which help to step back from oneself and accept
that life does not always follow ones wishes and goals. The goal
is not to solve problems but to teach problem-solving skills. This
is done by using the method of unsolvable dilemmas. The patients are given the description of some severe negative life event
which has been unjust, irreversible, without a clear solution and
not related to the present problem of the patient. There are 3
people involved, the victim, the offender and some third party.
In a structured learning process, the patient is asked to describe
his or her own feelings if he/she were the victim and what he/she
would do. Then the patient is asked to imagine that he/she is the
instigator of the problem or the third party and how he/she
would feel and think in this case. The reactions that would be
most harmful and add to injury are analyzed, which could be
helpful in the short or the long run. How would experts in the
management of difficult problems in life (e.g. manager, priest,
elderly person with much life experience, psychologist, lawyer,
etc.) approach the situation?
Hedonia Strategies. Treatment including hedonia strategies
followed a manual [21, 22]. Instead of focusing on what has happened, hedonia therapy also starts with a paradoxical approach
by supposing that well-being is a form of revenge, as it shows that
the offender has no power over the emotional state of the patient.
The patients are told that someone who has suffered deserves to
get something good. The goal therefore is distraction, self-care
and looking for the good things in life. This is especially important when intrusions provoke negative emotions. Special treatment techniques are to tell the patients that nobody can avoid
negative experiences but that it is important that there is a balance
between negative and positive aspects in life (pair of scales model). Next, the daily activities of the patients are analyzed and the

Psychother Psychosom 2011;80:199205

201

pretreatment

6
1.6

WH group

W group

posttreatment

1.52

5.03

1.4

4.64

4.45

1.25

1.21

1.2

SCL-90-GSI

2.62
2.33

1.71
1.06

1.16

1.0

3.1

2.94

1.12

1.62
1.25

1.07

0.82

0.8

0.75

0.69

0.6
0.4
0.2

te
-ra

er
-th

PTED W
(n = 28)

Fig. 1. Rating of wisdom and hedonia strategies. W = Wisdom

group; WH = wisdom and hedonia group; h-patient = rating of
hedonia strategies by the patient; h-therapist = rating of hedonia
strategies by the therapist; h-rater = rating of hedonia strategies
by a blind rater; w-patient = rating of wisdom strategies by the
patient; w-therapist = rating of wisdom strategies by the therapist;
w-rater = rating of wisdom strategies by a blind rater.

patients are encouraged to increase their rate of positive and distracting activities. They are also stimulated not to be preoccupied
by the overall problems in life, but to appreciate the little things
in life at every moment, e.g. while brushing ones teeth, looking at
the sun, walking along a river or dressing oneself. In little training
episodes they are asked to touch, smell and listen deliberately and
see what this does to them. They learn that one can influence how
one feels. A further topic is to analyze what can hinder a person
from being good to oneself. There are general rules of hedonia:
allow yourself to be good to yourself, take your time, take caring
for yourself seriously, focus on the little things, less is better than
more, one must learn to be good to oneself, being good to oneself
is a daily routine.
Treatment Integrity
Treatment integrity in the 2 special treatment modes was
measured with the Behaviour Therapy Compentency Checklist
[31], specially adapted to wisdom and hedonia strategies. Wisdom strategies were evaluated on 13 items (e.g. the patient is
asked to describe a problem from the perspective of a third party, or the patient is asked to describe short-term and long-term
consequences of an event) and hedonia strategies on 10 items
(e.g. the patient is asked to look for simple pleasurable things in
life, or it has been discussed that well-being can be improved
by pleasurable acitivities). Ratings per item were done on a

202

ap

ie
at
-p
w

ist

nt

r
te
ra
h-

ap
er
th
h-

h-

pa

tie

ist

nt

Psychother Psychosom 2011;80:199205

PTED WH
(n = 29)

PTED TAU
(n = 25)

all other patients

(n = 1,431)

Fig. 2. SCL-90-GSI self-rating before and after treatment.

7-step Likert scale (0 = does not apply at all, 1 = applies very

little, 2 = applies a little, 3 = applies somewhat, 4 = applies in
parts, 5 = applies mostly, 6 = applies fully). The average scores
across all wisdom or hedonia ratings serve as a measure for treatment integrity and can range from 0 to 6. All sessions were rated
for wisdom as well as hedonia strategies. Ratings by therapists
and patients were done independently of each other immediately after each session. Ratings by the observers were done after
the study had been finished and based on tape recordings of the
full session. These raters did not know which type of treatment
the tapes belonged to.
Statistical Analyses
Using ANCOVA statistics, GSI postscores for TAU, W and
WH were compared with GSI prescores as covariate. The global
clinical ratings of therapists and patients at the end of treatment
were compared with the nonparametric Kruskall-Wallis test of
variance. Additional pairwise comparisons between treatment
groups were done with the Mann-Whitney U test. Furthermore,
effect sizes are reported.

Results

Figure 1 summarizes the results of the ratings on treatment integrity. The therapists rated the application of
wisdom strategies in the W group with 4.45 on average
and in the WH group with 1.71. Correspondingly, they
rated the application of hedonic strategies in the WH
Linden/Baumann/Lieberei/Lorenz/Rotter

Table 2. Therapist and patient treatment evaluation

W
WH
TAU
Kruskal(n = 28) (n = 29) (n = 25) Wallis

W/WH
U1

TAU/W
U2

TAU/WH
U2

Has the treatment goal of the patient been reached?

(0 = not at all, 10 = in full)

7.46
(2.5)

7.38
(3.1)

5.93
(1.8)

p < 0.005

Has the treatment goal of the therapist been reached?

(0 = not at all, 10 = in full)

7.07
(2.3)

6.97
(3.1)

5.80
(1.86)

p < 0.058

Global disability rating

(10 = total disability, 90 = full capacity in all areas
of life)

66.8
(15.2)

66.2
(14.2)

58.7
(13.9)

p < 0.25

371
p < 0.57
[0.08]
384
p < 0.723
[0.04]
401
p < 0.928
[0.04]

181
p < 0.002
[0.69]
234
p < 0.028
[0.61]
219
p < 0.014
[0.56]

192
p < 0.003
[0.56]
225
p < 0.013
[0.45]
210
p < 0.006
[0.54]

5.71
(2.6)

5.60
(2.6)

3.88
(2.4)

p < 0.082

Was the stay in this hospital in general of help to you? 7.00

(0 = no at all, 10 = fully)
(2.9)

7.28
(2.9)

5.44
(3.1)

p < 0.069

Did you like the stay in this hospital?

(0 = no at all, 10 = fully)

7.34
(2.5)

6.31
(3.2)

p < 0.535

400
p < 0.917
[0.04]
381
p < 0.677
[0.10]
392
p < 0.821
[0.17]

228
p < 0.022
[0.69]
233
p < 0.028
[0.78]
275
p < 0.126
[0.54]

223
p < 0.028
[0.66]
233
p < 0.018
[0.61]
307
p < 0.226
[0.36]

Therapist

Patient
Has your personal treatment goal been reached?
(0 = not at all, 10 = fully)

7.71
(1.8)

Figures are means with SD in parentheses and values in square brackets represent effect sizes.
Mann-Whitney U test one-sided2 and two-sided1.

group with 4.64 and in the W group with 1.06. This difference shows the intention of the therapists to apply 2
different modes of treatment. Observers and patients also
see that there are marked differences in respect to hedonic strategies, which are applied to a much greater degree
in the WH group than in the W group (patients: 5.03 vs.
2.33, observers: 2.94 vs. 1.07). In respect to wisdom strategies, they report no difference between the WH and the
W group (patients: 2.61 vs. 3.10; observers: 1.25 vs. 1.62).
Observer ratings and especially patient ratings suggest
that the therapists applied wisdom strategies in both
groups and that in the WH group hedonic strategies were
additionally executed.
Figure 2 shows the results on the SCL-90-GSI before
and after treatment for the TAU, W and WH groups. An
ANCOVA with GSI postscores as dependent variable and
the GSI prescores as covariates showed, as can be expected, that pre- and postscores are significantly related to
each other (F 35.9, p ! 0.001). After controlling for the
prescores, there is still a significant difference between

the groups (F 15.9, p ! 0.001). For pairwise comparisons,

the ANCOVA shows significant differences between
TAU and W (p ! 0.005, effect size 0.82), TAU and WH
(p ! 0.002, effect size 0.94) and no difference between W
and WH (p ! 0.806, effect size 0.26). To help with the interpretation of the absolute scores, data from all other
inpatients of the department, who were suffering from a
variety of mental disorders, are additionally reported in
figure 2.
Table 2 shows the global ratings of treatment outcome by therapists and patients. Statistics from the
Kruskal-Wallis test show significant differences or
trends of differences between the groups, which are due
to differences between W and WH on one side and TAU
on the other, while there are no differences between W
and WH. Of interest is that the patient rating on how
they liked the stay in the hospital showed no difference
between the groups, which can be taken as validation of
the ratings, as it shows that there has not been a general
rating bias.

Cognitive Behaviour Therapy in

Posttraumatic Embitterment Disorder

Psychother Psychosom 2011;80:199205

203

Discussion

This is a first pilot study on the treatment of prolonged

embitterment reactions with cognitive behaviour therapy. Limitations of the study are that the patients have
been treated in an inpatient setting so that many unspecific or additional treatment influences can have an impact on the course of illness. The hospital is also giving
care to a very select group of patients so that the generalizability of results can be questioned. Also, cohort comparisons can give only limited proof of treatment efficacy.
Finally, the study comes from a research group which has
special interests in embitterment so that research biases
cannot be excluded.
The results from the TAU group confirm the clinical
impression that embitterment, which regularly includes
hopelessness, aggression, cynicism and rejection of help,
is difficult to treat [12, 13]. The results from pre-post
comparisons in the W and WH groups and the comparison with the TAU group suggest that treatment and improvement are possible. The comparison of the W and
WH groups indicates that hedonia and self-care strategies in addition to wisdom and reframing strategies do
not result in additional therapeutic benefits.
However, the question remains whether the treatment
effect is due to wisdom interventions as such or to the introductory part of treatment, or the combination of both.
The study cannot tell whether wisdom interventions are
indispensable. Both effective treatments had in common
an introductory part which was specifically targeted at
getting the cooperation of the patients. Pivotal strategies
have been (a) a very high degree of empathy and unconditional acceptance of the patient and even more his or
her distorted and aggressive views of the world, (b) a very
detailed description of intrusive thoughts, hurting emotions and avoidance behaviour, and (c) a paradoxical approach in the sense of improvement as revenge, i.e. not to
allow the aggressor to punish the patient twice, first by
the critical event and secondly by impaired well-being.
The clinical improvement could result from the fact that
the patient has learned to accept that treatment is needed
and that he or she should do something to change not the
world but oneself, and not from wisdom interventions.
Another question is whether wisdom psychology and
wisdom strategies are indispensable or whether classic
cognitive behaviour strategies may not be sufficient.
There is much experience with cognitive restructuring
[32], cognitive reframing [33] or reattribution techniques
[34], which have been shown to be of help in solving life
problems similar to embitterment. Further research will
204

Psychother Psychosom 2011;80:199205

have to clarify the specific and additional role of wisdom

psychology in contrast to these established treatment
approaches. There are also other treatment approaches
which deserve to be tested, like metacognitive therapy
[35], mindfulness-based cognitive therapy [36], acceptance and commitment therapy [37] or well-being therapy [24], which have also been used in posttraumatic disorders and have some similarities to our approach.
Nevertheless, referring to wisdom and the set of wisdom strategies like factual and procedural knowledge,
long-term perspective, empathy with the offender and
role change, emotional serenity, value relativism, etc., is a
promising avenue to cognitive reattribution, restructuring and problem-solving in PTED patients and possibly
also in patients who suffer from mischiefs of the outer
world in general. It comprises such psychological skills as
are needed when one wants to clarify what has happened
and what can be done next. Especially the technique of
unsolvable dilemma helps to teach the patient how to
analyze complex problems and how to solve unsolvable
problems by looking at what happened from a distant
perspective, without emotional overflow, by questioning
the patients feeling of uniqueness, and by consoling him
or her for the experience of injustice and humiliation.
The clinical impression is that this approach can be helpful not only in PTED patients but also in other cases of
reactive and adjustment disorders.
This is to our knowledge the first study on the treatment of PTED. Therefore, no comparisons with other
studies are possible. As already discussed, this early pilot
study leaves many methodological questions unanswered, like control with a placebo, selection of patients
or bias of researchers [38, 39]. However, the results of this
study justify further randomized controlled trials, which
should be done by independent researchers.

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