Mood disorders are some of the most common mental health illnesses for youth in the United States and affect 11 percent of 13- to 18-year-olds (NAMI, 2016). When diagnosed in youth (before 21-years-old), mood disorders last longer, respond more poorly to treatment, and have a higher likelihood of running in the family of the diagnosed (Barlow & Durand, 2011). Exacerbating this prognosis is the socially constructed “illness ideology,” which “dictates that the focus of [clinicians’] attention should be disorder, dysfunction, and disease rather than health, [and] emphasizes abnormality over normality, poor adjustment over healthy adjustment, and sickness over health” (Maddux, 2008, p. 56). Among the clinical implications of this socially constructed, deficits-based model of mental health are how 1) negative experiences stand out against positive experiences, 2) clients and clinicians arrive at negative experiences sooner than positive ones, 3) client’s emotions are typically dominated by negative emotions, and 4) negative experiences may invite deeper and more complex discourse between client and clinician when compared to positive experiences (Rashid, 2015).
The first encounter between youth and clinicians is the clinical assessment oftentimes, and the illness ideology, while having moved the field forward for decades, has serious shortcomings: 1) It assumes only symptoms matter; 2) it can reduce and objectify youth through labels that don’t tell their whole story; and 3) these assessments expose youth and clinicians to disproportionately more negatives (Rashid, 2015). How then might a strengths-based assessment provide a positive foundation for treatment of mood disorders in youth?
Dimensional, Not Categorical, Understanding of Psychopathology and Strengths
Klein’s pictorial representation of the various courses of mood disorders (Fig. 1) subtly illustrates the illness ideology’s deference to negatives: Only a state of euthymia is charted, a mood state characterized by neutrality and being problem-free, and different from hyperthymia, which is an excess of positivity to the point of symptomology. There seems to be no category in which a client can be more than “surviving,” problem-free. What seems to be missing is a state wherein clients do more than just get by, but possess strengths and thrive (Seligman, 2011). A dimensional approach to diagnosing disorders and strengths can address this discrepancy.
Perhaps it is useful to think of most constructs in psychopathology as needing to be scaled on two parallel dimensions: a) the undesirable or pathological attribute moving from severe deviance through some neutral point to its positive nonoccurrence and b) the antithetical attribute, moving from nonoccurrence through some neutral point to its desirable form. (Evans, 1993, p. 266)
For example, on the first dimension, dysthymia (Persistent Depressive Disorder) moves toward euthymia, a positive nonoccurrence. Likewise, the “antithetical attribute” on the second dimension moves from nonoccurrence to some desirable form like a character strength. Peterson (2006) takes this dimensional approach a step further: “Not having a strength may mean simply its absence [nonoccurrence], but it may also take more extreme forms: showing its opposite or its exaggerated version” (p. 38), which in the previous example is hyperthymia. Applying this concept to the character strength Hope is the objective of Table 1.
One study developed this idea slightly further.
Instead of viewing problems and strengths at the two ends of one continuum, therapists indicated striving for equal attention to both. Therapists saw problems and strengths as comprising two different continuums, making it possible to simultaneously concentrate on the client’s problems and his or her strengths. Problems and strengths were seen in balance. Too much emphasis on one would diminish or undeservedly minimize the other. (Scheel, Davis, & Henderson, 2012, p. 423)
Lastly, Rashid (2015) has developed this model to a logical conclusion by using the first comprehensive, coherent, and systematic effort to classify character strengths (Peterson & Seligman, 2004) as a lens through which to view psychological disorders as more than just symptoms but as lacking and excessive strengths. A short excerpt is included in Table 2.
Vossler, Steffen, and Joseph (2015) note that positive psychology has already been incorporated into clinical psychology through concepts unrelated to assessment like posttraumatic growth, resilience, “build what’s strong/fix what’s wrong,” and gratitude. The authors suggest one way clinical psychology can further incorporate positive psychology is through “a stronger emphasis on and recognition of positive elements inherent in traditional therapeutic approaches” (p. 437). In clinical assessment of youth, the Center for Epidemiologic Studies Depression Scale—Revised (CES-D; Radloff, 1991) has shown efficacy with youth and contains some elements of well-being that clinicians can widen in the course of their positive practice (Rashid, 2015).
Rashid (2015) also promotes the use of valid and reliable measures focusing solely on strengths such as the Value in Action Inventory of Strengths (VIA-IS; Peterson & Seligman, 2004), but Bird, et al. do not recommend VIA-IS for clinicians because of its lack of validity and reliability for mental health populations (Bird, et al., 2012), having been developed primarily for the general population. Following their wide review of strength-based assessments (n=12), Bird, et al. recommended the Strengths Assessment Worksheet (SAW; C. A. Rapp & Goscha, 2006; R. C. Rapp, et al., 1994) and Client Assessment of Strengths, Interests, and Goals (CASIG; Wallace, et al., 2001): “Although a number of strengths assessments are currently available, due to the limited amount of evaluative research, only…the CASIG and the SAW” can be tentatively recommended for routine use in clinical settings (Bird, et al., 2012, p. 1031). While Magyar-Moe (2009) lists a number of strengths-based assessments, including the Clifton StrengthsFinder 2.0 for adults and youth and StrengthsExplorer (CSF 2.0; CSE; Asplund, et al., 2007; Rath, 2007) for ages 10-14, this measure wasn’t reviewed by Bird et al. because it was developed with the general population in mind rather than a mental health population. More work remains to ensure the validity and reliability of these measures for clinical settings.
If clinicians are unable to utilize vetted strength-based measures, they can supplement their standard assessments with measures like VIA-IS or CSE with the understanding that a focus on strengths in these cases will require more time for client and clinician alike. When choosing measures to supplement traditional clinical assessment, Seligman’s (2011) PERMA conceptualization of well-being can serve as a useful model for clinicians to enhance, not necessarily increase, the Positive emotion, Engagement, positive Relationships, Meaning, and Achievement. For example, a clinician, working with a youth can use the Steen Happiness Index (SHI; Seligman, et al., 2005) as a supplement to Beck’s Depression Inventory (BDI; Beck, et al., 1961). The use being limited to supplementing the BDI rather than replacing it in clinical assessment because of Bird, et al.’s exclusion of it in their review.
Because mood disorders affect a large percentage of youth, and the “illness ideology” exacerbates the serious shortcomings of clinical assessment, a strengths-based assessment is encouraged to build on preexisting strengths in youth as a strengths-based foundation to positive psychological treatment. A dimensional conceptualization of disorders and strengths does this by striving to enhance well-being. Lastly, clinicians can refocus their assessment of mood disorders in youth using validated and reliable strength-based measures or by supplementing their assessment with measures to highlight what clients already have “going for them,” as a platform from which to jump into positive psychological interventions in treatment.
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