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New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses (3rd post)

I do enjoy writing these blog posts ... real fun having the opportunity to think around subjects that currently intrigue me.  So in the first post in this sequence on the value of a therapeutic focus on strengths rather than weaknesses we looked fairly broadly at this area.  In the second post the discussion moved to the importance of "making a flying start" in psychotherapy and then homed in on the Cheavens et al study - "The compensation and capitalization models: A test of two approaches to individualizing the treatment of depression" - that triggered this whole exploration.  So how did Jennifer Cheavens & colleagues go about focusing on patient strengths rather than weaknesses?  Well they developed four treatment modules with module strategies "drawn from cognitive-behavioral treatments for MDD (major depressive disorder) with empirical support for their efficacy."  

They went on to describe the four modules in more detail - "Behavioral-module (B-module): In the B-module, therapists focused on counteracting withdrawal, reducing avoidance, and increasing engagement with potential reinforcers. Therapists emphasized establishing mastery, adding pleasant events, and structuring daily activities.  Specific strategies included activity monitoring, managing contingencies to increase the likelihood of engaging in new behavior, and evaluating behaviors in terms of goals and values.  Cognitive module (C-module): In the C-module, therapists focused on helping patients to identify and re-evaluate thoughts and interpretations associated with negative affect.  Therapists emphasized developing skepticism about the validity of automatic thoughts and developing more realistic views through consideration of evidence.  Specific strategies included use of thought records to facilitate this identification and reevaluation, and reducing vulnerability to emotions through self-care.  Interpersonal module (I-module): In the I-module, therapists emphasized the development, maintenance, and utilization of social support as well as enhancing interpersonal skills, including assertiveness and self-respect.  Therapists focused on communication skills and increasing interpersonal interactions.  Specific strategies included assertiveness skills (e.g., methods of asking for help and declining requests from others), social skills, and efforts to develop or enhance relationships.  Mindfulness module (M-module): In the M-module, therapists focused on building and increasing skills related to observation and description of internal and external experiences with reduced reactivity to these experiences.  Therapists emphasized maintaining attention in the present moment and reducing judgments of experiences.  Specific strategies included mindfulness practices (e.g., following breath, body scan, mindful walking) as well as noticing and letting go of difficult experiences (i.e., acceptance)."

Each patient was randomized either to two modules that were assessed as being their relative strengths (capitalization) or to two modules assessed as being their relative weaknesses (compensation).  So the authors wrote - "Interviewers assessed participants' strengths and deficits in four domains related to cognitive-behavioral interventions (i.e., cognitive strategies, interpersonal skills, behavioral activation, and acceptance practices). Across the four domains, interviewers asked patients to describe their use of strategies when they were feeling depressed or down (e.g., adopting a new perspective, calling on a social support network). Each domain was assessed through the use of five questions assessing strategies patients might use (in a semi-structured interview created for this study). For example, when assessing the mindfulness/acceptance domain, interviewers asked the patients about experiences of engaging in behaviors out of habit, without thinking about the present moment, and the ability to tolerate emotions without needing to get rid of them immediately. Patients who reported using strategies in a given domain more frequently and with better mastery were more likely to have that domain labeled as a relative strength.  Evaluators were asked to designate, based on the patient responses to the interview, the two "greatest relative strengths" and the two "greatest relative weaknesses" without allowing for overlap in the two categories."
Interestingly the percentage assessed as having relative strengths in each area was 62% behavioural, 58% mindfulness, 44% interpersonal, and 35% cognitive.

Patients were randomized to 16 weeks of therapy.  Those who responded (no longer met criteria for Major Depressive Disorder and Hamilton Rating Scale score of less than 12) were followed up for a further 12 months.  During this time they could have up to a further 3 booster sessions (using the same treatment module interventions as during their initial therapy).  So what happened?  Well, patients randomized to treatment modules focusing on their strengths responded significantly better and faster.  This was particularly the case during the first 4 weeks of therapy.  Subsequently, over the next 12 weeks, this head start in improvement was maintained.  By 16 weeks, 12 of 17 (71%) "strengths" patients were responders compared with only 9 of 17 (53%) "deficits" patients.  Note, if one looked at the response to the different modules overall, there was no difference in either response or drop-out rates.  These important differences in therapy effectiveness do seem to be due to randomisation to strengths rather than deficits treatments.  And the lack of focus on deficits didn't come back to "bite" the strengths focus patients over follow-up.  In fact only 2 of the 12 (17%) strengths treatment responders relapsed over the next 12 months compared with 4 of the 9 (44%) deficits treatment responders.   

So what do I make of this?  Well the number of patients involved is small, but the difference in outcome is definitely impressive.  As I argued in the first of the three blog posts in this sequence, although it is much more usual for therapists to use treatments to try to remedy deficits rather than build on strengths, the previous research literature actually also suggests that a strengths focus is likely to be more helpful.  The authors themselves wrote "Our results provide preliminary evidence that the capitalization approach is superior to the compensation approach of selecting treatment strategies. If replicated, our results would offer a serious challenge to much of the commonly held beliefs about how therapists can best adapt treatment to suit different patients. Beyond replication, future research with larger samples might also examine the mechanisms through which the capitalization model may outperform the compensation model. For example, patients might be more likely to experience an initial success with a capitalization approach. That initial success and the accompanying positive affect, particularly early in treatment, may lead to increased engagement in treatment. While we did not evaluate whether initial success with treatment methods and greater engagement in treatment might explain the superiority of the capitalization approach, we think this is an important possibility worthy of attention in future work.  Future research on psychometric development is also needed.  The difference between the treatment approaches we tested relied critically on our assessment of patients' relative strengths and deficits. To assess these strengths and deficits, we used a semistructured interview involving forced-choice rankings of relative strengths and deficits. We believe that the questions we asked in this interview likely reflect the kind of information that therapists would garner in clinical interviews in early therapy sessions.  However, future research to assess the validity of our measure or to create self-report measures that could be used in lieu of a structured interview is needed."

OK, so it's still early days, but there's enough here (including the associated research studies) to affect my treatment approach when trying to help someone suffering from depression (and probably other disorders as well).  I note that Fluckiger et al - "Focusing the therapist's attention on the patient's strengths: a preliminary study to foster a mechanism of change in outpatient psychotherapy" - encouraged therapists to spend 10 minutes, just before each of their first 5 sessions with a patient, thinking about the sufferer's particular strengths.  I don't think I'll take 10 minutes, but I intend to be even more thorough in the initial assessment at asking about & noting down patients' personal strengths & resources.  This is to include asking them what strategies they already use when they are distressed (and how successful they find them).  Then before & at the start of especially initial sessions with the patient, I also want to remind myself of their strengths and quite possibly ask about & celebrate their use of these approaches. 

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