Strength-based assessment of mood disorders in youth

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.

  Figure              SEQ Figure \* ARABIC         1            .   Pictorial representation of various course configurations of non-bipolar depression.  The horizontal axis represents time and the vertical axis represents mood, with the horizontal black line representing euthymic, or normal, mood, and the magnitude of downward deflection (the blue area) reflecting severity of depressive symptoms.  Panel (a) is non-chronic major depressive disorder (in this case, recurrent, as two depressive episodes are depicted).  Panel (b) is dysthymic disorder.  Panel (c) is double depression (major depressive episode superimposed on antecedent dysthymic disorder).  Panel d) is chronic major depressive episode.  Panel (e) is major depressive episode in partial remission.  Panel (f) is recurrent major depression without full interepisode recovery.  (Klein, 2010, p. 97)

Figure 1.  Pictorial representation of various course configurations of non-bipolar depression.  The horizontal axis represents time and the vertical axis represents mood, with the horizontal black line representing euthymic, or normal, mood, and the magnitude of downward deflection (the blue area) reflecting severity of depressive symptoms.  Panel (a) is non-chronic major depressive disorder (in this case, recurrent, as two depressive episodes are depicted).  Panel (b) is dysthymic disorder.  Panel (c) is double depression (major depressive episode superimposed on antecedent dysthymic disorder).  Panel d) is chronic major depressive episode.  Panel (e) is major depressive episode in partial remission.  Panel (f) is recurrent major depression without full interepisode recovery.  (Klein, 2010, p. 97)

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.

  Table 1.   Peterson’s (2006) conceptual model of character strengths applied to Persistent Depressive Disorder (dysthymia) and Hope, a character strength defined as “expecting the best in the future and working to achieve it; believing that a good future is something that can be brought about” (p. 33).

Table 1.  Peterson’s (2006) conceptual model of character strengths applied to Persistent Depressive Disorder (dysthymia) and Hope, a character strength defined as “expecting the best in the future and working to achieve it; believing that a good future is something that can be brought about” (p. 33).

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.

  Table 2.   The dysregulation of strengths in the mood disorder Major Depressive Episode.  (Rashid, 2015, p. 526)

Table 2.  The dysregulation of strengths in the mood disorder Major Depressive Episode.  (Rashid, 2015, p. 526)

Strength-Based Assessments

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.

Conclusion

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.

References

Asplund, J., Lopez, S. J., Hodges, T., Harter, J.  (2007).  Technical report: Development and validation of the Clifton StrengthsFinder 2.0.  Princeton, NJ: Gallup.

Barlow, D. H. & Durand, V. M.  (2011).  Mood disorders and suicide.  In Abnormal psychology: An integrative approach (6th ed.).  Belmont, CA: Wadsworth.

Beck, A. T., Ward, C., Mendelson, M.  (1961).  Beck depression inventory (BDI).  Archives of General Psychiatry, 4, 561-571.

Bird, V. J., Le Boutillier, C., Leamy, M., Larsen, J., Oades, L. G., Williams, J., & Slade, M.  (2012).  Assessing the strengths of mental health consumers: A systematic review.  Psychological Assessment, 24(4), 1024-1033.  doi:10.1037/a0028983

Evans, I. M.  (1993).  Constructional perspectives in clinical assessment.  Psychological Assessment, 5, 264-272.  doi:10.1037/1040-3590.5.3.264

Klein, D. N.  (2010).  Chronic depression: Diagnosis and classification.  Current Directions in Psychological Science, 19(2), 96-100.  doi: 10.1177/0963721410366007

Maddux, J. E.  (2008).  Positive psychology and the illness ideology: Toward a positive clinical psychology.  Applied Psychology: An International Review, 57, 54-70.  doi:10.1111/j.1464-0597.2008.00354.xp

NAMI.  (2016).  Mental health facts: Children and teens.  Retrieved from http://www.nami.org

Peterson, C.  (2006).  The Values in Action (VIA) classification of strengths.  In M. Csikszentmihalyi & I. Csikszentmihalyi (Eds.), A life worth living: Contributions to positive psychology (pp. 29-48).  New York: Oxford UP.

Peterson, C., & Seligman, M. E. P.  (2004).  Character strengths and virtues: A handbook and classification.  New York: Oxford UP/Washington DC: American Psychological Association.

Radloff, L. S.  (1991).  The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults.  Journal of Youth and Adolescence, 20(2), 149-166.  doi:10.1007/BF01537606

Rapp, C. A., & Goscha, R. J.  (2006).  The strengths model: Case management with people with psychiatric disabilities (2nd ed.).  New York: Oxford UP.

Rapp, R. C., Kelliher, C. W., Fisher, J. H., & Hall, F. J.  (1994).  Strengths-based case management: A role in addressing denial in substance abuse treatment.  Journal of Case Management, 3, 139–144.

Rashid, T.  (2015).  Strength-based assessment.  In S. Joseph (Ed.), Positive psychology in practice: Promoting human flourishing in work, health, education, and everyday life (2nd ed.) (pp. 519-542).  Hoboken, NJ: Wiley.

Rath, T.  (2007).  StrengthsFinder 2.0.  New York: Gallup Press.

Scheel, M. J., Davis, C. K., & Henderson, J. D.  (2012).  Therapist use of client strengths: A qualitative study of positive processes.  The Counseling Psychologist, 41, 392-427.  doi:10.1177/0011000012439427

Seligman, M. E. P.  (2011).  Flourish: A visionary new understanding of happiness and well-being.  New York: Free Press.

Seligman, M. E. P., Steen, T. A., Park, N., Peterson, C.  (2005).  Positive psychology progress: Empirical validation of interventions.  American Psychology, 60, 410-421.

Vossler, A., Steffen, E., & Joseph, S.  (2015).  The relationship between counseling psychology and positive psychology.  In S. Joseph (Ed.), Positive psychology in practice: Promoting human flourishing in work, health, education, and everyday life (2nd ed.) (pp. 429-441).  Hoboken, NJ: Wiley.

Wallace, C. J., Lecomte, T., Wilde, J., & Liberman, R. P.  (2001).  CASIG: A consumer-centered assessment for planning individualized treatment and evaluating program outcomes.  Schizophrenia Research, 50, 105-119. doi:10.1016/S0920-9964(00)00068-2

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