Strength-based methods – a narrative review and comparative multilevel meta-analysis of positive interventions in clinical settings

Figures & data

Table I. Prior meta-analyses of strength-based treatments.

Authors	k	N	Targeted mental health suffering	Treatment	Comparison	Primary Outcome	Effects
Bolier et al. (2013)	39	6139	Psychosocial problems	PPI	NI, WL, TAU, PL	WB, DS	Effects after removing outliers (I^2 non-significant): Increase in subjective WB: d = 0.26, 95%-CI [0.18, 0.33], Z = 6.43, p < .01 Increase in psychological WB: d = 0.17, 95%-CI [0.09, 0.25], Z = 4.18, p < .01 Decrease in DS: d = 0.18, 95%-CI [0.07, 0.28], Z = 3.33; p < .01
Chakhssi et al. (2018)	30	1864	Mental and somatic disorders	PPI	AC, NI, WL	WB, DS	Effects after removing outliers and low-quality studies: Increase in WB: g = 0.19, 95%-CI [0.02, 0.37], p < .03, I^2 = 40.9% Decrease in DS: g = 0.07, 95% CI [−0.19, 0.32], p = .60; I^2 = 66.1%
Munder et al. (2019)	10	918	Mental disorders	RFT	WL, AC	PS, IF, QoL	Superiority of RFT compared to TAU in 8 out of 11 comparisons: gPPWC = 0.349, 95%-CI [0.576, 0.122], p < .003, I^2 = 46.50% gPOWC = 0.190, 95%-CI [0.355, 0.025], p < .02; I^2 = 0.00%
Sin and Lyubomirsky (2009)	51	4266	Depressive symptoms	PPI	NT PL, TAU, NC	WB, DS	Increase in WB: Zr = 0.29 (range: −0.31, 0.84), p < 0.001, χ^2(48) = 230.92 Decrease in DS: Zr = 0.31 (range: −0.28, 0.81), p < 0.001, χ^2(24) = 146.32
White et al. (2019)	51/ 39	4266/ 6139	Depressive symptoms, psychosocial problems	PPI	NT, WL, TAU, PL	WB, DS	Replications accounting for SSSB and omitting outliers: Sin and Lyubomirsky (2009): Increase in WB: r = .10, 95%-CI [-.01, .20] (Q(38) = 70.68, p < .001) Decrease in DS: r = -.03, 95%-CI [-.17, .11], (Q(19) = 26.82, p = .11) Bolier et al. (2013): Increase of subjective WB: r = .13, 95%-CI [0.00, 0.26] (Q(22) = 57.39, p < .001) Increase in psychological WB: r = .02, 95%-CI [-.09, 0.13] (Q(15) = 18.41, p = .24) Decrease in DS: r = .15, 95%-CI [.06, .24] (Q(11) = 11.51, p = .40)
Hoppen and Morina (2021)	20	1360	Mental and somatic disorders	PPI	WL, active treatment		WL: Increase in positive outcomes: g = 0.72, 95%-CI [0.14, 1.31] Decrease in negative outcomes: g = 0.48, 95%-CI [0.18, 0.78] Active treatment: Increase in positive outcomes: g = 0.92, 95%-CI [0.11, 1.74] Decrease in negative outcomes: g = 0.94, 95%-CI [0.18, 1.70]

Notes: k = number of studies included; N = patient sample size; MDD = Major Depression Disorder; AfD = Affective Disorders; PSD = Psychotic Spectrum Disorders; AnD = Anxiety Disorders; SD = Stress Disorders; DD = Dissociative disorders; PD = Personality Disorders; ADHD = Attention Deficit Hyperactivity Disorder

Treatments: PPI = Positive Psychology Intervention; RFT = Resource-focused Treatment; AC = active control group; PC = passive control group; PL = placebo; NT = no treatment; NC = neutral control group; TAU = treatment as usual; WL = waitlist

Outcomes: WB = well-being; DS = depressive symptoms; BMI = body-mass index; PS = primary symptoms; IF = interpersonal functioning; QoL = quality of life; d = Cohen’s d; g = Hedges’ g; Z_r = mean Fisher effect size; PPWC = pre-post with control; POWC = post-test only with control, OR = odds ratio; RR = risk ratio; SSSB = small study size bias; Q = Cochran’s Q (residual heterogeneity).

Figure 1. Flowchart of the included process-outcome studies and comparative trials (s = studies, k = effect sizes).

Table II. Summary of strengths-based process-outcome studies investigating bona fide psychotherapy.

Authors	Sess.	N	Disorder	Inpatient/Outpatient	Treatment	Process measure	Summary of immediate and delayed in-session effects
Flückiger et al. (2009)	96	36	Mixed / SAD	Outpatient	ICBT	ROMA-T; ROMA-P	Comparable quality of SBM across two strength-based approaches. Personal skills highest associated with the patient’s post-session evaluations of mastery (r = .44), personal goals highest association with clarification/insights (r = .49). Quality of SBM (r = .39, p < .01) correlated with the extent of goal achievement (GAS-R) at session 10
Regli et al. (2000)	168	45	Mixed	Outpatient	ICBT	GCFA	Successful vs. less successful therapies: significant difference in quality of SBM during the first few therapy sessions (higher quality of SBM in successful therapies). Therapy with above-average alliance vs. below-average alliance: significantly higher quality of SBM in therapies with above-average alliance)
Kech (2008)	112	20	MDD	Inpatient	IPT	GCFA	Successful therapies: high emotional activation with simultaneous high quality of SBM (r = .52, p < 0.001). Opposite effect in unsuccessful therapies: high emotional activation but simultaneously low quality of SBM (r = - .13; p = .30)
Gassmann and Grawe (2006)	120	30	Mixed	Outpatient	ICBT	CMP	In successful therapy and therapy sessions: Quality of SBM positively associated to patient strength-based in-session talks (r > .20). In less successful therapies: high quality of SBM but low levels of patient strength-based talks at the end of sessions
Flückiger and Studer (2009)	108	48	Mixed	Outpatient	ICBT	ROMA-T; ROMA-P	Personal skills and personal goals predicted shift into deeper emotional stages during sessions. After a shift, patients usually reframed or normalized their behavior.
Flückiger et al. (2014)	20	20	GAD	Outpatient	ICBT	ROMA-P	Personal skills at the beginning of sessions followed a more problem-focused stage that was characterized by a higher level of negative emotional expressions during therapy
Schilling et al. (2021)	89	89	Mixed	Outpatient	ICBT	ROMA-T; ROMA-P	Sessions before a substantial increase of symptoms: personal goals and positive reinterpretations significantly mentioned earlier in the sessions (p < .01)
Smith and Grawe (2003, 2005)	740	128	Mixed	Outpatient	ICBT	GCFA	Association of quality of SBM and session outcome composite (d = 0.85). In-session process: In situation where the patient do not respond to the therapist’s proposed method (20.92%), subsequent discussion about personal skills enhances the chance to turn into a productive session (51.1%).

Notes: N = patient sample size; ICBT = Integrative Cognitive Behavioral Therapy; IPT = Interpersonal Psychotherapy; MDD = Major Depression Disorder; GAD = Generalized Anxiety Disorder; SAD: Social Anxiety Disorder; SBM = Strength-based methods (therapist); ROMA-P/ ROMA-P, Resource-Oriented Microprocess Analysis (Patient-/ Therapist-Version); CMP = Consistency Theory Micro-Process Analysis; (Grawe, 1997, 2004), GCFA = General Change Factors (Grawe, 1999). Scores at study level: + =  mainly positive associations with facilitative in-session effects, 0 = mixed or nondistinctive associations with facilitative in-session effects, − = mainly negative associations with facilitative in-session effects.

Table III. Comparative trials contrasting strength-based methods with bona fide psychotherapy.

Study	Patient population	Gender (% male)	Mean age (years)	Depression or anxiety comorbidities excluded	SUD excluded	Bona fide strengths-based psychotherapy	Bona fide comparison psychotherapy	N	Study-level effect size (g)
Boyer et al. (2015)	ADHD	74	14.5	yes	yes	Solution-focused Therapy + Motivational Interviewing	Manualized CBT (Plan My Life) + Motivational Interviewing	159	−0.07
Cheavens et al. (2012)	Major depression	41	37.0	no	yes	Modular CBT for depression: Two treatment modules were selected to reflect individual patients’ strengths	Modular CBT for depression: Two treatment modules were selected to reflect individual patients’ deficits	42	0.52
Flückiger et al. (2008a)	multidiagnostic (depression & anxiety)	45	35.4	no	yes	Custom tailored CBT: (a) Case formulation of patients’ strengths, (b) use of resource-focused methods (e. g. positive reframing, planning pleasure, imaginative techniques) in addition to CBT as usual	Custom tailored CBT: (a) Case formulation without augmented focus on patients’ strengths, (b) use of CBT as usual	40	0.39
Flückiger, Forrer et al., (2016)	GAD	25	43.9	no	no	Manualized CBT for GAD (MAW): (a) Case formulation of patients’ strengths, (b) tailoring CBT to match patients’ strengths	Manualized CBT for GAD (MAW): (a) Case formulation of patients’ GAD symptoms and comorbidities, (b) tailoring CBT to match patients’ GAD symptoms	57	0.22
Flückiger et al. (2021)	GAD	25	31.4	no	no	Manualized CBT for GAD (MAW): (a) Case formulation of patients’ strengths, (b) tailoring CBT to patient’s change behaviors	Manualized CBT for GAD (MAW): (a) Case formulation of patients’ GAD symptoms and comorbidities, (b) tailoring CBT to match patients’ GAD symptoms	80	0.08
Knekt et al. (2008, 2013, 2015)	multidiagnostic (depression & anxiety)	32	24.4	no	yes	Solution-focused Therapy	Short-time psychodynamic therapy	198	0.06
Kosfelder (2000)	Anxiety disorder	34	31.0	no	yes	Custom tailored CBT: CBT + Solution-focused methods (focus on previous solution attempts, early change, compliments)	Custom tailored CBT: use of CBT as usual	75	−0.04
Teismann et al. (2011)	Major depression	33	46.0	no	yes	Manualized CBT for depression: (a) Solution-focused methods (focus on previous solution attempts, early change, compliments), (b) strengths-oriented modification of CBT techniques (e.g., finding functional cognitions without elaborating dysfunctional cognitions)	Manualized CBT for depression: use of CBT as usual	70	0.07
Willutzki et al. (2004)	SAD	58	38.2	yes	yes	Manualized CBT for SAD: (a) Solution-focused methods (focus on previous solution attempts, early change, compliments), (b) strengths-oriented modification of CBT techniques (finding functional cognitions without elaborating dysfunctional cognitions)	Manualized CBT for SAD: use of CBT as usual	83	0.42

Notes: effect sizes in favor to SBM, ADHD = Attention deficit hyperactivity disorder, GAD = Generalized anxiety disorder, SAD = Social anxiety disorder, SUD = Substance use disorder, CBT = Cognitive behavioral therapy, MAW = Mastery your Anxiety and Worry, NN = Nearest Neighbor method, RS = Retrospective Sample.

Figure 2 Forest plot - Relative efficacy in favor of strength-based methods vis à vis bona fide psychotherapy (s = 9 studies, k = 57 effect sizes, 804 patients).

Figure 3 Funnel plot of the 9 comparative trials.

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