I wrote a post a few days ago entitled "Resource activation: using clients' own strengths in psychotherapy and counseling - background (1st post)" giving some of the research basis for suggesting this territory is very relevant for therapists who are pushing to help their clients more effectively.  In order to follow up these ideas further I bought the short 'how to do it' 70 or so page book by Fluckiger, Wusten, Zinbarg & Wampold.  In his 'Foreword', Bruce Wampold comments "The practice of psychotherapy and counseling is dedicated to helping individuals lead happier, more productive, and satisfying lives by helping to relieve the distress that motivated them to seek help. Thus, there is a focus on distress remediation ... It is quite easy to be coerced or maybe even seduced into the medicalization of psychotherapy and counseling ... Simply put, great forces are being exerted to address distress.  It is not surprising then that we can easily forget that clients bring to therapy an immense array of strengths.  Clients often have difficulties in a particular area (e.g., marital relationship) but are successful in others (e.g., their career) ... The dichotomy between remediation of symptoms and distress versus health and growth is a false one, however ... focusing on strengths in therapy is not incompatible with existing treatments; incorporating therapeutic actions that utilize client strengths makes existing treatments more effective.  (The book) Resource activation - using clients' own strengths in psychotherapy and counseling" provides pragmatic strategies that can be - or, rather, should be - used in therapy to help clients recognize and use their strengths. Sometimes therapeutic strategies involve simply changing the way we ask questions, focusing on coping and success rather than frustration and failures.  Others involve more elaborate exercises to assist the client in recognizing and using their existing coping strategies, developing new strategies, and using their strengths.  The questions, strategies, and exercises in this volume are deceptively simple, but often simple changes produce the best outcomes.  However, a change of therapist attitude is needed - redirecting ourselves from a focus on symptoms and distress to a focus on client strengths."

Whatever the background mechanisms, the research clearly suggests that we can improve outcomes by adding more of a focus on strengths.  This is true if, like Cheavens et al, we choose approaches that clients have affinity for rather than simply trying to correct areas of weakness.  Sotsky et al uncovered further support for capitalization v's compensation approaches with their analysis of outcomes from the landmark NIMH study on depression - they "investigated patient characteristics predictive of treatment response" and fascinatingly found that "Low social dysfunction predicted superior response to interpersonal psychotherapy" while "Low cognitive dysfunction predicted superior response to cognitive-behavior therapy".  In the first chapter of their short book (mentioned above), Fluckiger & colleagues describe a system of "resource analysis" which can help us keep an initial broad focus when looking at this area.  I have slightly adapted their "Identifying strengths & resources" diagram (downloadable here as a Powerpoint slide or as a PDF file) and am exploring filling it in with clients using a one, two or three "tick" system to note their personal strengths & resources (see this sheet for the sorts of questions one might ask).  Noteworthy too is the recent paper by Priebe et al - "Resource-oriented therapeutic models in psychiatry: conceptual review" - with their comment that "Like other medical specialties, psychiatry has traditionally sought to develop treatments targeted at ameliorating a deficit of the patient. However, there are different therapeutic models that focus on utilising patients’ personal and social resources instead of ameliorating presumed deficits.  A synopsis of such models might help to guide further research and improve therapeutic interventions ... Ten models were included: befriending, client-centred therapy, creative music therapy, open dialogue, peer support workers, positive psychotherapy, self-help groups, solution-focused therapy, systemic family therapy and therapeutic communities.  Six types of resources were utilised: social relationships, patients’ decision-making ability, experiential knowledge, patients’ individual strengths, recreational activities and self-actualising tendencies.  Social relationships are a key resource in all the models, including relationships with professionals, peers, friends and family ... Conclusions: The review suggests that a range of different therapeutic models in psychiatry address resources rather than deficits.  In various ways, they all utilise social relationships to induce therapeutic change." (I have slightly adapted the "Identifying strengths & resources" diagram - adding a "closeness & activities" reminder box to reflect this relationship emphasis).

It's worth remembering that the benefits of working with strengths may act by more than one mechanism.  So the capitalizing method involves encouraging clients to use therapeutic methods that fit with their strengths & interests.  A somewhat different technique is illustrated in the early Fluckiger paper "Focusing the therapist's attention on the patient's strengths" where encouraging results were achieved by getting therapists to spend a few minutes before the start of each of the first five therapy sessions reminding themselves of the client's strengths & resources.  Looking over the previously completed "Identifying strengths & resources" diagram is an easy & helpful way of doing this.  Reminding oneself of a client's strengths pre-session can deliberately be linked to trying to touch on strengths/resources near the start of the session and again towards the end.  The value of this touch-on-strengths/resources both early & late in session approach is particularly highlighted in Gassmann & Grawe's paper "General change mechanisms: the relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions" with its comment " ... the relation between two general change mechanisms, problem activation and resource activation, was studied with the focus on (1) patient behaviour and (2) therapist intervention. The unit of analysis was one minute. The results show that problem and resource activation play different roles in the process of change: problem activation alone did not reliably lead to therapeutic progress; only when combined with thorough resource activation could it unfold its therapeutic potential.  Successful therapists chose different degrees of and different timing in applying the two change mechanisms than unsuccessful ones.  The results indicate that clearer conceptualizations and specific therapist training are necessary to make better use of resource activation."  The BPS Digest reported on this paper saying "Research is increasingly showing that the success of therapy depends not on the theoretical orientation of the therapist, but on key therapeutic processes that cross theoretical boundaries.  Two such processes are ‘problem activation’ – helping the client to face up to their problems, and ‘resource activation’ – reminding the client of their strengths, abilities and available support.  In a new study, Daniel Gassmann and the late Klaus Grawe have shown that for therapy to be successful, simply using these mechanisms is not enough; rather, success depends on how and when the mechanisms are brought into play.  Gassman and Grawe’s research team studied videos of 120 therapy sessions conducted with 30 clients who had a range of psychological problems.  The success of each therapy session had also been reported by the clients and therapists on a session-by-session basis.  From minute-by-minute analysis of the sessions, the researchers found that unsuccessful therapists tended to focus on their clients’ problems, but neglected to focus on their strengths. Moreover, when the unsuccessful therapists did focus on their clients’ strengths, they tended to do so at the end of a therapy session, too late to have a positive effect.  Successful therapists, by contrast, focused on their clients’ strengths from the very start of a therapy session, before moving onto dealing with their problems.  “They created an environment in which the patient felt he was perceived as a well functioning person”, the researchers said.  “As soon as this was established, productive work on the patient’s problems was more likely”.  Successful therapists also made sure they ended sessions by returning to their clients’ strengths.  The researchers concluded that a prerequisite for successfully dealing with a patient’s problems is to remind them of their strengths and available support.  “The therapist can achieve this not only by establishing a good therapeutic bond”, they said, “but also by focussing more explicitly on the healthy parts of the patient’s personality”.

So I'm experimenting with filling in the "Identifying strengths & resources" diagram (downloadable as a Powerpoint slide or as a PDF file)  with clients and then glancing at it myself before each session with them (at least over the first few appointments).  I want to refer to their strengths/resources both early and towards the end of each session.  It makes sense as well to experiment with tracking how I do using the "Resource priming sheet" suggested by Fluckiger & colleagues in their book.  Here's the "Priming sheet" downloadable as a Word doc and here as a PDF file ... and here's an example of a completed sheet provided by the authors.

More to follow ...