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New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses (1st post)

In 2010 Simon & Perlis highlighted the importance of being better able to match depression sufferers to treatment approaches that were more likely to benefit them.  In their paper "Personalized medicine for depression: Can we match patients with treatments?", they wrote: "Response to specific depression treatments varies widely among individuals. Understanding and predicting that variation could have great benefits for people living with depression ... The authors ... review evidence related to three specific treatment decisions: choice between antidepressant medication and psychotherapy, selection of a specific antidepressant medication, and selection of a specific psychotherapy ... The limited evidence indicates that some specific clinical characteristics may inform the choice between antidepressant medication and psychotherapy and the choice of specific antidepressant medication. Research to date does not identify any biologic or genetic predictors of sufficient clinical utility to inform the choice between medication and psychotherapy, the selection of specific medication, or the selection of a specific psychotherapy. Conclusions: While individuals vary widely in response to specific depression treatments, the variability remains largely unpredictable ... At this time, our inability to match patients with treatments implies that systematic follow-up assessment and adjustment of treatment are more important than initial treatment selection."

Well I have no problem with encouraging "systematic follow-up assessment and adjustment of treatment" as needed.  In fact I would underline the importance of doing this for both symptom level and for the therapeutic alliance - see, for example, the earlier blog post I wrote entitled "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".  But what about personalizing treatments to better suit individual clients?  Jennifer Cheavens & colleagues - in their recent paper "The compensation and capitalization models: A test of two approaches to individualizing the treatment of depression" - write "Patients differ in the degree to which they have pre-existing strengths or deficits in the areas targeted by different intervention strategies. When therapists provide treatment, they may use strategies with known overall efficacy (e.g., challenging distorted thoughts, increasing behavioral activation, strengthening social networks, heightening awareness of links between emotions, thoughts, and behaviors); however, patients likely are not uniformly skilled in these areas and might respond to these strategies differentially as a result. Pre-existing strengths and deficits in targeted domains could be used in individualizing treatment either by choosing to reduce relative deficits (i.e., compensate) or to build upon relative strengths (i.e., capitalize) in target areas. According to the compensation model, treatments will be more successful insofar as they target the relative deficits in patients' disorder-relevant vulnerabilities. In contrast, the capitalization model would lead one to expect treatments to be more successful insofar as treatment involves targeting patients' relative strengths.  Most, if not all, of the well-supported psychotherapies for depression are based on conceptualizations involving treatment strategies thought to remedy vulnerabilities associated with depression."

The authors go on to note some 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.  In the next post, I'll look much more at the recent Cheavens et al study, which has some overlap with this Fluckiger et al work but is more impressive in research terms and more powerfully suggests we should consider altering our practice to focus more on strengths when working to help with depression, and probably anxiety & other symptoms as well. 

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