"In psychotherapy, is it better to boost current skills or mitigate deficits?"

I just discovered this important question. If we go beyond the question of depression alone and ask a more general question about the psychotherapies - from psychoanalytic to behavioral and cognitive therapies to relational therapies, we can discern more general patterns of what happens in therapy.

Using information theory and systemic therapy as a model (but this applies to all therapies), we do three simple things in therapy (Di Nicola, 1997):

• Enhance uncertainty (show that their current repertoire is limited or that their way of framing things can be improved)
• Introduce novelty (suggest other ways of examining the problem from new perspectives)
• Encourage diversity (stimulate new ways of thinking and being, beyond their current repertoire in order to be more adaptive to current and future challenges)

So, my specific answer to this question - "In psychotherapy, is it better to boost current skills or mitigate deficits?" - is that another option is missing which is to introduce novelty, new ways of looking at things and new ways of living. This means in the frame of this question, new skills, as opposed to boosting skills already in place or mitigating lack. Let me be clear: offering to model or teach new skills is not necessarily addressing a lack. It may simply be the case that the person never confronted a given situation and needs to add to their repertoire of skills.

Vincenzo Di Nicola, MPhil, MD, PhD

Université de Montréal &

The George Washington University

Reference: Di Nicola, V. (1997). A Stranger in the Family: Culture, Families, and Therapy. New York & London: WW Norton & Co.

In some cases it is better to boost already existing skills, in other to encourage new achievements to support a change in symptoms.

Michael,

I was talking about change in symptom expression in case they do not fall off

Based on my clinical experience, I agree in general with the position of boosting existing skills of clients in psychotherapy in preference to addressing areas of deficit. In fact, the skills represent strength which can be figuratively nourished to dominate the pathological components or areas of deficit. This principle has been recognised by Arron Anthonovsky in 1983 which he referred to as salutogenesis as opposed to pathogenesis.

Fascinating question... and my guess is depending on someone's training they may answer slightly differently..... After 30+ years in the field.... I really like the concept of Resilience......Basically it assumes everyone has the skill set somewhere in side them to sort things out but in moments of tragedy, depression, grief etc... they need to be reminded and guided back to that place..... and that may mean looking at behaviors that get in the way of getting back to that constructive skill of theirs to be resilient and return to normal functioning..... Hope that helps!

Boost the current skills!

I think it is a matter of which one is causing the most difficulty - or which one will lead to the greater improvement in functioning. Some deficiencies may be so acute that they take priority over other objectives. With other persons, it may the case that that increasing skills will provide the greatest improvement in overall functioning. It's a good question. Perhaps there is not a one-size-fits-all solution. This is why we call it "clinical." Each professional has to evaluate the complexities and nuances of each individual and put the problem (often not well articulated) and information (often unstructured) and objectives (often under-specified) together. Just my .02

As a clinician w/ over 40 years in behavioral healthcare, I do both. Client strengths do account significantly to + outcomes. Many of the conditions I've treated and involve significant health and life threatening aspects which need to be stabilized first.

Rich

Yes, psychotherapy is most effective when it boosts already-existing capacities and skills, rather than when it focuses on ameliorating deficits. But i think that depends on a case to another. I use both.

In the Netherlands we call the one “supportive” psychotherapy and the other one “discovering” psychotherapy. Although

what you call “focussing on the deficits” is not what psychotherapists do. “Discovering” psychotherapy is aimed at going to the core of the problem andsupportve therpy is buildding on sssucssfful straties alrlsd present.

In Dutch “ondersteunende psychotherapie” versus “openleggende psychotherapie”

Whether you do the one or the other depends on certain characteristics of the patient.

1. Are they able to introspect?

2. Do they have enough inner structure? Object constantancy, whhole objet internlisaion, etc.

3. To what extent are they able to tolerate frustration?

4. To what extent are they able to defer gratification?

If there are a lot of No- answers, then that patient is not suitable for “discovering” psychotherapy and needs supportive therapy, which boils down to identifying those defence mechanisms that work for the patient and strengthen them, in the hope the less successful defence mechanisms and coping strategies diminish.

If there are many “yes- answers”, then the patient is suitable for more and lengthier discovering therapy where one is able to search for pattens in present bhaviour and to go back to earlier and/or childhood situations Where these mal-adaptive patterns started.

I think that many historical approaches to psychotherapy were heavily focused on pathology. In addition to this, some of the older approaches assumed that change required many sessions of psychotherapy (i.e., the larger the dose the more sure the outcome). Sometime in the 1980's studies began to appear that suggested most clients (patients) attended 10 (or fewer) therapy sessions. More significantly, however, was an emergent trend that sought to engage the client or patient as an active collaborator in the therapeutic process. Over the course of several years this trend has resulted in the following approaches to counseling and interviewing:

• Solution Focused (Brief) Therapy (e.g., de Shazer & Berg)
• Narrative Therapy (e.g., Michael White)
• Competency Based Counseling (e.g., Bob Bertolino)
• Single Session Therapy (e.g., Moshe Talmon)
• Motivational Interviewing (e.g., William R. Miller & Stephen Rollnick).

The literature on these approaches demonstrates the efficacy of these methods of working with individuals (even those who may be assessed as living with significant concerns). In addition, my experience as a clinician and a clinical mentor has provided me with many opportunities to observe that people can move towards meaningful change (sometimes in a single session) when they are engaged as a collaborator in a therapeutic process that honors their awareness, competencies, and resources.

Hi Marc Josep Garcia Hervás:

I think the answer to your question depends a great deal on your theoretical perspective. Psychodynamic therapists w/a Positive Psychology perspective will agree with you. It will also depend on where you are employed, but to a much lesser degree. As one w/an eclectic theoretical perspective, I think there are times when a therapist must do both. Strengthening positive coping skills and capacities is very important. The client needs something to put in place of the issues for which they come to a therapist. But if that client is a narcissistic personality disorder or traits, is that individual capable of recognizing the more maladaptive behaviors & thought patterns? In such a case, it seems to be a razor's edge of balance between lessening the maladaptive & increasing the functional aspects of the individual's personality.

This balancing on the razor's edge is also applicable to individual's who are incarcerated. There is something not working in their character that has crossed the line set by society. Whether that is a coping skill, IQ, or whatever it is important that this individual be met w/that delicate blend of strengthening their positives and decreasing their negatives.

Sorry about not having literature back-up. My opinion comes from working in a wide variety of populations w/an even broader racial/ethnic heritages for a quarter of a century. Gee that sounds old!:)

I hope this helps & wish you well in your search to find out the answer.

Denise

When depression is treated, it must be understood that the cause of depression is not in a mental disorder, but in an organic one, which is a mental disorder. Based on this, the use of psychotherapy in the treatment of depression is ineffective. But, unfortunately, nothing else is applied except medication. The use of psychotherapy is an ineffective tool that does not eliminate the cause of depression and does not completely eliminate depression. Psychotherapy smoothes depression for a while. I have found the manifestation of nervous disorders, which is the cause of depression. By the force of influence on the psyche, this phenomenon can be stung with an atomic bomb, and psychotherapy with a weak defensive strike. The cause of depression is organic and effectively treated depression by eliminating an organic disorder, and not psychotherapy. If you have a broken finger, you will not treat it with psychotherapy. Depression is a breakdown of the body that needs to be treated with certain means.

"In psychotherapy, is it better to boost current skills or mitigate deficits?"

I just discovered this important question. If we go beyond the question of depression alone and ask a more general question about the psychotherapies - from psychoanalytic to behavioral and cognitive therapies to relational therapies, we can discern more general patterns of what happens in therapy.

Using information theory and systemic therapy as a model (but this applies to all therapies), we do three simple things in therapy (Di Nicola, 1997):

• Enhance uncertainty (show that their current repertoire is limited or that their way of framing things can be improved)
• Introduce novelty (suggest other ways of examining the problem from new perspectives)
• Encourage diversity (stimulate new ways of thinking and being, beyond their current repertoire in order to be more adaptive to current and future challenges)

So, my specific answer to this question - "In psychotherapy, is it better to boost current skills or mitigate deficits?" - is that another option is missing which is to introduce novelty, new ways of looking at things and new ways of living. This means in the frame of this question, new skills, as opposed to boosting skills already in place or mitigating lack. Let me be clear: offering to model or teach new skills is not necessarily addressing a lack. It may simply be the case that the person never confronted a given situation and needs to add to their repertoire of skills.

Vincenzo Di Nicola, MPhil, MD, PhD

Université de Montréal &

The George Washington University

Reference: Di Nicola, V. (1997). A Stranger in the Family: Culture, Families, and Therapy. New York & London: WW Norton & Co.

Vincenzo,

Your response is an excellent one and clarifies the pertinent psychotherapeutic opportunities which are transtheoretical BTW.

Rich

Thank you, Richard Kensinger.

We need more synthetic, transtheoretical and transdisciplinary thinking and get well beyond the therapy wars of the 1990s.

Warmly,

Vincenzo

Thank you all so much for such invaluable insight! I enjoyed the humanistic flair of most of your responses, which gives, I believe, a new dimension to the question. I liked Lilian Hupkens's psychoanalytic view too, though I get the sense that her approach –precisely perhaps because of its psychoanalytic nature– would favor what she calls “discovering” psychotherapy, while strengthening defense mechanisms would be the less-preferred, sub-optimal choice for patients unable to introspect. Vincenzo Di Nicola's systematic answer was very helpful too!

For those of you more interested in boosting skills rather than addressing areas of deficit, I’d like to recommend Parks and Schueller (2014)’s handbook of positive psychology interventions*. There is a chapter in it by Vella-Brodick, named “Dovetailing ethical practice and positive psychology to promote integrity, industriousness, innovation, and impact” (pp. 416-432), which addresses the apparent split between “positive” and “negative” psychology; while not exactly what I was asking, the chapter is rich with useful information.

As for Vasil Grigoriev's approach, I’ve got to say that as far as I know, depression is in fact a combination of both biological and psychological vulnerabilities, according to so-called “diathesis-stress models”. I would certainly not go as far as to say that psychotherapy is ineffective in the treatment of depression, since reviews and meta-analyses compiling evidence from thousands of patients in RCTs have concluded not only that psychotherapy has better outcomes in the long run (see Article Psychotherapy and Medication in the Treatment of Adult and G...

Article Psychological therapies for treatment-resistant depression in adults

Again, thank you all so much for being a part of this conversation!

Best,

Marc

* Parks, A., & Schueller, S. (2014). The Wiley Blackwell handbook of positive psychological interventions. Malden: Wiley Blackwell.

Marc Josep Garcia Hervás The ultimate goal in the treatment of the disease is the complete elimination of the symptoms of the disease and the complete restoration of the functions disturbed by the disease. Studies of the effectiveness of psychotherapy show some improvement in the condition of patients with depression, but do not demonstrate cases of complete elimination of depression. How does psychotherapy work for depression? Psychotherapy does not manipulate the primary cause of depression. Psychotherapy can somewhat reduce the symptoms of depression and is a procedure for adapting to a destructive state. For example, you have symptoms of depression, you applied psychotherapy and this allowed you to adapt to a destructive state. However, the primary cause of depression is not affected. The destructive processes that led to depression are not eliminated by psychotherapy and continue to develop in the future. Psychotherapy allows you to adapt to a destructive situation, but does not allow you to fully restore the normal course of physiological functions. The key mechanism of the demonstrated effect of psychotherapy on depression is the mechanism of adaptation to life in conditions of substantial loss of the body's functionality. And these functional disorders are a significant loss in quality of life. Therefore, various reviews may demonstrate some success in relieving the symptoms of depression, but these successes are a demonstration of the success of adaptation to a negative situation, which continues to progress and may later lead to the emergence of other diseases. Psychotherapy is not a means of fully treating depression, but can only reduce the severity of the symptoms of depression for some time.

There are at least two broad approaches to psychotherapy: problem-solving and solution-building ones (De Jong & Berg, 2013). Problem-solving approaches focus on remedying the problems such as psychodynamic psychotherapy, cognitive behavior therapy, etc. Solution building therapies concentrate on tapping into the strengths, existing skills and potential of the client; they include solution-focused brief therapy (SFBT), narrative therapy (NT) and positive psychology.

Both approaches are effective in their own ways. To choose which approach is more suitable depends on the client's needs, problems strengths and resources; the therapist's personality, training and preferences; and the relationship between the client and the therapist, etc. (Cheung, 2009, 2018, 2019).

I love the simplicity and richness of your answer. Thank you, Dr. Stephen Cheung! If it's not too much trouble, may I have the full references for those works you cited? I'd love to have a look and learn more about this.

Vasil Grigoriev, thanks a lot for your detailed and well-reasoned replies. I do see your point. If we were to agree that the etiology of depression is exclusively biological, then I would say your arguments are valid. As far as I know (though I am by no means an expert on this), depression emerges as the result of *both* physiological as well as psychological vulnerabilities. I’m not arguing that psychotherapy can bring everyone to complete remission, but it should be able to address the needs that derive from that component of psychological deficits, not merely boost somebody's resilience against a state of inevitable suffering.

Difficult question. We might spend all our life without discovering all our skills. Leaving the comfort zone and experiencing challenges will help us find the best of ourselves.

Both! You need to use current skills and strengths to strengthen weaknesses.

Counseling 101 recommends to build on the client's strengths rather than focusing on deficits or weaknesses. If the therapist is able to help the client recognize their strengths and build upon it and relate them to the coping mechanisms that the client has used successfully it is far more significant than trying to eliminate or minimize their weaknesses. Once the client;s strengths are enhanced and recognized it would be automatically easy for the client to overcome their weaknesses.

Marc Josep Garcia Hervás Thanks for your kind comments.

I've been teaching family therapy (modern therapies) and postmodern therapies. I'd see that a lot of the modern therapies are problem-solving, assume the expert role, and therefore espouse a some-knowing therapeutic stance. In contrast, postmodern therapies are more solution-building, strengths-based, and egalitarian, and espouse a not-knowing therapeutic stance.

Here are the references you requested:

Cheung, S. (2009). Solution-focused brief therapy. In J. Bray & M. Stanton (Eds.), The Wiley-Blackwell Handbook of family psychology (pp. 212-225). Wiley-Blackwell Publishers.

Cheung, S. (2018, June). Multicultural group therapy for Asian immigrants with severe mental disorders. A workshop presented at the 22nd World Congress of Psychotherapy: Psychotherapy, Stronger through Diversity, organized by the International Federation for Psychotherapy in Amsterdam, the Netherlands.

Cheung, S. (2019, March). An integrated multicultural treatment approach for bulimia nervosa. A workshop presented at Hong Kong Baptist University in Hong Kong.

De Jong, P. & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Belmont, CA: Thomson Higher Education.

Weather to INCREASE skills(increase Approach coping skills-Moos,1993, increase Positive affectivity-Watson & Tellegen 1985,,increase trait hypnotizability-Wickramasekera 1977,increase Social support- House et al 1988) or REDUCE deficits( reduce Avoidance coping skills,reduce Catastrophizing,reduce Negative affectivity,reduce Self -deception(Crowne & Marlowe 1960,Jensen 1987) is an empirical question ,based on the INDIVIDUAL patient's profile of risk, on the High Risk Model of Threat Perception(Wickramasekera 1979, 1987,1988,1995,2003).

It is also very important to have REAL time quantitative measures of clinical outcome(both implicit and explicit) to determine if your interventions to(reduce deficits,or increase skills) are impacting salient clinical goals( " Increasing the ability to work and love" Freud).

I am including two controlled case studies (Wickramasekera 1994,Wickramasekera & Wickramasekera 11,1997) to illustrate this method of REDUCING( ) assets is integrated into CBT & Psychodynamic therapy.

Ian Wickramasekera PhD

The salary of a company employee is a reward for performing certain actions. The reward system of the brain pays for performing certain actions that the brain considers important to the body. Income can increase if someone gives us money or you can borrow money and increase income. If we assume that depression is a bad mood, then we can stimulate the factors that elevate mood and reduce the influence of factors that decrease mood. The change in employee salary in a company determines the overall level of employee income. If an employee loses his job, then the reward may become zero. Attempts to borrow money do not solve the general problem of income. The brain reward system will ignore attempts to manipulate mood through the stimulation of positive mood factors and the avoidance of negative mood factors if the target brain task for which it pays the reward is not fulfilled. Depression is not just a bad mood, it is a violation of highly organized functions. And depression is a symptom of these disorders. Manipulating the symptom does not solve the problem of depression itself. The solution to the problem of depression is a highly organized transdisciplinary remedy and cannot be solved by increasing positivity or reducing negativity.

I don't think it has to be a binary understanding. In most (but not all) cases, I would say it is both; using the former to ameliorate the latter.

The use of various methods of psychotherapy in the presence of functional and organic problems in 99% of patients will have a random result that does not reflect the real impact of a particular method of psychotherapy. The influence of various methods of psychotherapy is influenced by the direction of development of organic problems. In order to reliably know which method in psychotherapy is better, it is first necessary to eliminate organic problems that have a random effect on the course of depression. Now psychotherapy in the treatment of depression is a means of adaptation to organic problems. The effect of psychotherapy in treating depression is too small compared with the effect of organic and functional problems on the psyche.

Looking at just skills seems to narrow the question a little. I've had clients who needed to change jobs because physically they could not perform the current one any longer or their place of employment downsized or closed. One of the approaches I have found useful is helping the client identify their 'career anchors' as described by Edgar Schein. He has identified 8 career preferences some of which individuals will gravitate toward in choosing jobs as an example. Some people like independence, creativity, making a difference, being the manager, stability and security and so forth. Once an individual recognizes there are opportunities that will still allow him or her to have these preferences, progress begins. They may need new skills or polish up old ones, it depends on the situation.

What is still missing from this discussion is SPECIFICITY in the proposals for types of 1) skills and types of 2) deficits to increase the EFFICACY of psychotherapy.

It is very important to separate out recommendations of clinical EFFICACY based on controlled empirical studies(meta analysis etc) from clinical folk LORE, empirically unvalidated" theories" and uncontrolled anecdotal case studies.

The empirical evidence is consistent with the superiority of Approach coping skills over Avoidance coping skills(Moos 1993).

The empirical evidence is consistent with the ability of increased Positivity Affectivity to BUFFER or reduce psychopathology and somatization( Petrie et al 2018,Stanton & Watson 2014).

The empirical evidence is consistent with the ability of a High number & or High Satisfaction with Social Support people to reduce lifetime rates of morbidity and mortality(House et al 1988,Mihalopoulos etal 2019,Holt-Lunstad & Smith 2015 ,Wilson et al 2018)

Best regards.