A bit over two years ago I wrote a sequence of three blog posts starting with "New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses".  This was triggered by the fascinating paper by Cheavens & colleagues "The compensation and capitalization models: A test of two approaches to individualizing the treatment of depression" - with its abstract reporting "Despite long-standing calls for the individualization of treatments for depression, modest progress has been made in this effort. The primary objective of this study was to test two competing approaches to personalizing cognitive-behavioral treatment of depression (viz., capitalization and compensation). Thirty-four adults meeting criteria for Major Depressive Disorder (59% female, 85% Caucasian) were randomized to 16-weeks of cognitive-behavioral treatment in which strategies used were selected based on either the capitalization approach (treatment matched to relative strengths) or the compensation approach (treatment matched to relative deficits). Outcome was assessed with a composite measure of both self-report (i.e., Beck Depression Inventory) and observer-rated (i.e., Hamilton Rating Scale for Depression) depressive symptoms. Hierarchical linear modeling revealed a significant treatment approach by time interaction indicating a faster rate of symptom change for the capitalization approach compared to the compensation approach (d=.69, p=.03). Personalizing treatment to patients' relative strengths led to better outcome than treatment personalized to patients' relative deficits. If replicated, these findings would suggest a significant change in thinking about how therapists might best adapt cognitive-behavioral interventions for depression for particular patients."  (For more on this study click through to the third blog post of the sequence).

I went on in that first post to note other recent developments in taking a more capitalizing, strengths-based approach.  Fluckiger et al, for example, have published interesting work in this area - see their papers "Focusing the therapist's attention on the patient's strengths: a preliminary study to foster a mechanism of change in outpatient psychotherapy" and "Working with patients' strengths: a microprocess approach".  Other interesting relevant publications include Rashid & Ostermann's "Strength-based assessment in clinical practice", Huta & Hawley's "Psychological strengths and cognitive vulnerabilities: Are they two ends of the same continuum or do they have independent relationships with well-being and ill-being?" and Macaskill's "A feasibility study of psychological strengths and well-being assessment in individuals living with recurrent depression".

I find both Huta and Fluckiger's work particularly intriguing here.  Veronika Huta comes more from a positive psychology/self-determination theory perspective and this governs her particular take on "strengths".  Fluckiger's studies are perhaps more immediately related to the Cheavens research with the respective abstracts to the papers quoted above reading "Previous research has supported the immediate activation of patient's strengths (resource activation) as an important mechanism of change in psychotherapy. We designed a brief (10 min) priming procedure in which therapists' attention was focused on the patients' individual strengths before each therapy session (resource priming). In a preliminary study, the priming procedure was carried out before each of the first five sessions (N=20). Preliminary results indicated that this brief preparatory intervention boosted resource activation as perceived by independent observers, fostered attachment and mastery experiences by the patient, and improved therapy outcome at Session 20. Improvement was assessed in comparison to a pairwise matched, nonrandomized control group of patients treated previously with the same treatment protocol at the same clinic." and "Previous research has supported the immediate activation of patients' strengths (resource activation) as an important change mechanism in psychotherapy. Two different studies of integrative cognitive-behavioral therapy (CBT) treatments demonstrated that fostered strengths-oriented CBT treatments were more effective than the control conditions. Within these two studies, the authors tested the effect of specific resource-activating strategies at the beginning of therapy (Sessions 2, 5, and 8) using a pairwise matched control group design. The in-session processes were measured by video observer ratings (N=96 sessions). Results indicate that in the strengths-fostering treatments therapists and patients focus more strongly on patient competencies and personal goals in comparison to the control groups. These in-session processes have a direct impact on session outcome (particularly self-esteem, mastery, and clarification experiences). Results are discussed in regard to actively implementing resource-activating behavior as superordinate principles of change and their relevance for therapy outcome."

Fascinating stuff. Note how helpful it seemed for therapists to think about their clients' strengths and then help activate them ... both personal strengths of the clients themselves and strengths of resources/social support that the clients had access to.  Note too that this was particularly emphasised in the early sessions and that it resulted in stronger focus on client competencies and personal goals.  Interestingly, in more recent research by Fluckiger - "Resource activation in generalized anxiety--an observer-based microprocess analysis of patients' in-session outcomes" - the researchers found that patients who focused on their competencies (usually earlier in a treatment session) and who went deeper into emotional distress (usually later in the session) tended to get better treatment outcomes.  This reminds me of findings in the self-affirmation literature that self-affirmation tends to help people be open to more challenging information.  So, for example, Legault et al reported in their paper "Preserving integrity in the face of performance threat: Self-affirmation enhances neurophysiological responsiveness to errors" that "Even a simple reminder of one’s core values reduces defensiveness against threatening information."   This makes sense and overlaps with research from the attachment field showing that attachment security promotes openness to exploration - see Mikulincer et al's "An attachment perspective on therapeutic processes and outcomes."  Maybe one reason why early focus on client strengths/resources seems helpful is that it gives them the confidence to subsequently work more deeply into material that is emotionally important for them (although there are probably other mechanisms at work as well).

For more on what focusing on strengths might involve, see the next blog post in this sequence.