Strength based treatment plan

Strengths-Based Therapy (Guide) | Therapist Aid

Research in positive psychology has shown us that people who know their strengths and use them frequently tend to feel happier, have better self-esteem, and are more likely to accomplish their goals. However, many people have a hard time identifying their strengths (4). They see them as ordinary, even when they are not.

In order for people to use their strengths effectively, it’s important that they have a clear idea of what they are and how they can be used. Therapists can be instrumental in helping clients discover and use their strengths.

This guide will demonstrate how you can identify your clients’ strengths, teach clients to spot strengths in others, help clients become familiar with their own strengths, and finally, help clients develop and use their strengths to create positive changes in their lives.

Discovering Client Strengths

Familiarize yourself with strengths.

Strengths are natural capabilities and skills that each person has. When a person uses their strengths, they tend to feel energized, and they report higher levels of self-esteem, well-being, and other desirable outcomes. Studies have indicated that strength-based positive psychology interventions might reduce depression, and contribute to successful goal completion (2, 7).

Below, you'll find a list of strengths, and a worksheet that makes them easily printable.

Strengths Exploration

worksheet

Look for signs of strength in your client.

The first step of a strengths-based intervention, as you might expect, is to learn about your client’s unique strengths. You will achieve this by asking direct questions, and observing body language, emotion, tone, and behavior.

Asking about strengths.

Although many people have a hard time identifying their strengths, asking direct questions is a good place to begin.

What are you good at?
What do you enjoy doing?
In what areas of your life have you been most successful?

Be sure to hone in on core strengths, rather than specific skills. For example, “basketball” isn’t a strength, but “athleticism” and “discipline” are. You can do this by asking questions such as “What makes you good at basketball?” or “What about yourself allowed you to be successful in this area?”.

Use your knowledge of the client’s life to probe further. For example, if your client has been married for 15 years, ask about that. What has allowed them to maintain a long-lasting relationship?

Some strengths are invisible to the person who possesses them. Imagine an astronomer studying a black hole. Because a black hole is invisible, the astronomer looks at the effects of the black hole on its surroundings — the gravity it creates.

In a similar way, seemingly invisible strengths can be spotted by the way they affect a person’s life. One good way to help a client spot strengths is to ask questions about what they enjoy, what activities they gravitate toward, and when they are happiest. The answers usually point toward their strengths.

Strengths Discussion Questions

worksheet

What sort of activities fill you with energy?
Tell me about the best experience you remember having.
What makes a day really good for you?
When do you feel you were at your best during the past week?
What are your goals for the future?
What traits do you admire in other people?

None of these prompts ask directly about strengths, but their answers will often provide clues. By paying close attention to your client’s responses—including their tone and body language—you can start to detect strengths even they haven't noticed.

Watching for strengths.

Body language, tone, emotion, and behavior are excellent clues for spotting strengths. To see for yourself, try asking your client to spend five minutes discussing a weakness, and then five minutes discussing a strength. Take note of the differences in body language.

adapted from Linley, P. A. (2008)

Not everyone will display the exact same body language, but generally when clients are happy and absorbed in a subject, it's a good indication that they're talking about a strength. Learning to spot these clues will help you notice them even when you aren’t specifically looking.

In addition to body language, pay attention to your client’s actions. What activities do they gravitate toward, and where do they seem to have the most success? Because these tendencies might seem ordinary to your client who has lived with them their whole life, it would be a mistake to rely on self-reported information. Pay attention to their stories and other in-session observations to paint an even better picture of their strengths.

Signs of Strengths

Being drawn to things that allow for use of the strength.
Desiring to use the strength and feeling drained if not using it.
Prioritizing tasks that require use of the strength.
Desire to learn new information related to the strength.
Sense of energy and engagement when using the strength.
Having success when using the strength.

adapted from Linley, P. A., & Burns, G. W. (2010)

Teach your client the strength-spotting mindset.

Have you ever had the experience of learning a new word, then hearing it everywhere? Learning to spot strengths works in a similar way. When a person learns to spot strengths, they’ll begin seeing them everywhere. By learning to spot strengths in others, your client will eventually start to notice strengths in themselves, along with several other benefits.

adapted from Linley, P. A., & Burns, G. W. (2010)

Teach your client to notice others’ strengths using the same signs that clued you in on their strengths. Try the following exercises to encourage your client’s strength-spotting ability.

Exercise: Ask your client to list three strengths for each of the following people. How do their strengths reveal themselves?

a close friend
someone they admire
an acquaintance

Exercise: Encourage your client to keep a strength-spotting journal. In this journal, your client will make a daily entry where they describe three strengths they noticed in other people. These can be three strengths in one person, or spread between several people.

Example Entry

My husband has a great sense of humor. I had a bad day at work, but he helped me see the absurdity of the situation.
I saw LeBron James in an interview after a basketball game, and I noticed that he's exceptionally media savvy and socially aware.
My daughter must've asked 100 questions this evening. She's very curious, which I believe is a strength.

Developing and Enabling Strengths

After your client has discovered their strengths, the next step is to further develop and use them. Guide your client toward new situations where they can use their strengths, or toward new ways their strengths can be used to deal with current problems.

Strengths Exploration

worksheet

Finally, discuss practical steps your client can take to better utilize their strengths. How can they better use their strengths to deal with existing problems? What new activities can they try to use their strengths more frequently?

Exercise: Ask your client to think of a new way to deal with an existing problem using their strengths. Encourage your client to share specific details about how they would accomplish this.

Next, ask your client to think of a completely new way they could use their strengths. This could be a new hobby or project, a career change, or any number of other ideas. Again, ask for specific details of how this would be accomplished.

The following example illustrates how a strengths-based intervention might look in practice.

Example: Emily is a stay-at-home mother. Prior to becoming a mother, she pursued a demanding career as a marine biologist. Due to this major life change, some of the strengths she used to utilize, such as ambition and curiosity, have become underutilized.

In a strengths-based intervention, Emily and her therapist create a plan that will enable her to continue using her strengths in her role as a mother. Emily decides to begin teaching her daughter about science once a week through fun activities. Additionally, Emily starts to work a few hours a week from home as an editor for colleagues’ research papers.

Other Resources

Strengths-based interventions are a powerful component of positive psychology. To learn more about using strengths in therapy, check out these resources:

Casebook Collection For Applying Positive Psychology in Therapy

book

Character Strengths Interventions: A Field Guide for Practitioners

book

1. Biswas-Diener, R., Kashdan, T. B., & Minhas, G. (2011). A dynamic approach to psychological strength development and intervention. The Journal of Positive Psychology, 6(2), 106-118.

2. Govindji, R., & Linley, P. A. (2007). Strengths use, self-concordance and well-being: Implications for strengths coaching and coaching psychologists. International Coaching Psychology Review, 2(2), 143-153.

3. Linley, P. A. (2008). Average to A. Realising strengths in yourself and others. Coventry, UK: CAPP Press.

4. Linley, P. A., & Burns, G. W. (2010). Strengthspotting: Finding and developing client resources in the management of intense anger. Happiness, healing, enhancement: Your casebook collection for applying positive psychology in therapy, 1-14.

5. Linley, P. A., Nielsen, K. M., Gillett, R., & Biswas-Diener, R. (2010). Using signature strengths in pursuit of goals: Effects on goal progress, need satisfaction, and well-being, and implications for coaching psychologists. International Coaching Psychology Review, 5(1), 6-15.

6. Park, N., & Peterson, C. (2009). Character strengths: Research and practice. Journal of college and character, 10(4).

7. Seligman, M. E., Rashid, T., & Parks, A. C. (2006). Positive psychotherapy. American psychologist, 61(8), 774.

Strengths-based approaches for working with individuals

This Insight provides an overview of the research evidence on effective strengths based approaches for working with individuals and presents selected illustrative examples, written by Lisa Pattoni.

Key points

Strengths-based approaches value the capacity, skills, knowledge, connections and potential in individuals and communities.
Focusing on strengths does not mean ignoring challenges, or spinning struggles into strengths.

Practitioners working in this way have to work in collaboration - helping people to do things for themselves. In this way, people can become co-producers of support, not passive consumers of support.
The evidence for strengths-based approaches is difficult to synthesise because of the different populations and problem areas that are examined in the literature.
The strengths approach to practice has broad applicability across a number of practice settings and a wide range of populations.
There is some evidence to suggest that strengths-based approaches can improve retention in treatment programmes for those who misuse substances.
There is also evidence that use of a strengths-based approach can improve social networks and enhance well-being.

Why strengths-based practice, and why now?

With the growing focus on self-directed support (Scottish Government, 2010a), self-management of illness and long term conditions (Scottish Government, 2008a), and working together to achieve better outcomes (Christie, 2011), there is increasing interest in identifying and building on the strengths and capacities of those supported by services, as a means to help them resolve problems and deliver their own solutions. Strengths-based approaches concentrate on the inherent strengths of individuals, families, groups and organisations, deploying personal strengths to aid recovery and empowerment. In essence, to focus on health and well-being is to embrace an asset-based approach where the goal is to promote the positive.

Many are of the view that use of strengths-based approaches will be instrumental in successfully shifting the balance of care, and develop services that are focused on prevention and independence (Scottish Government, 2010b). This will challenge social services' historical focus on clients' deficiencies to a focus on possibilities and solutions (Saleebey, 2006). In effect, the strengths perspective is the social work equivalent of Antonovsky's salutogenesis which highlights the factors that create and support human health rather than those that cause disease (Antonovsky, 1987). Both emphasise the origins of strength and resilience and argue against the dominance of a problem-focused perspective.

Often, in traditional practice, the patient or client's role is often no more than the repository of the disease or the holder of the diagnosis: their personal characteristics or individual decisions are rarely considered, except where these support diagnosis (eg Type A personality in cardiac care) or impede treatment (eg non-adherence to medication) (Badenoch, 2006). Research by Hook and Andrews (2005) suggests that a person seeking support contributes as much to the chances of a successful outcome in an intervention as either the practitioner or their technique. Therefore, personal factors may predict more of the outcome than therapeutic rapport and intervention combined. This furthers the argument for routinely considering the individual's contribution (strengths) to the effectiveness of therapies, rather than treating the person as a passive recipient.

What is strengths-based practice?

Strengths-based practice is a collaborative process between the person supported by services and those supporting them, allowing them to work together to determine an outcome that draws on the person's strengths and assets. As such, it concerns itself principally with the quality of the relationship that develops between those providing and being supported, as well as the elements that the person seeking support brings to the process (Duncan and Hubble, 2000). Working in a collaborative way promotes the opportunity for individuals to be co-producers of services and support rather than solely consumers of those services (Morgan and Ziglio, 2007).

Some researchers have criticised strengths-based approaches citing that they are not in fact new or different from many other traditional approaches (McMillen, Morris and Sherraden, 2004) and that they are not based on evidence of efficacy (Staudt, Howard and Drake, 2001). Indeed, as interest has grown in this perspective, members of different disciplines in the sector are trying more positive approaches and using different words to describe it. For example, in mental health there is a strong focus on recovery and positive psychology - an inherently strengths-based perspective (Petersen and Seligman, 2004). In community development, the term 'asset-based' is used to describe communities as areas of potential rather than areas that are lacking (Kretzmann and McKnight, 1993). Prevention practitioners use words such as 'resilience' to describe an individual's ability to function well and achieve goals despite overbearing stresses or challenges.
For practitioners, these differences in terminology can often lead to confusion and misunderstanding. Indeed, even if people understand the approach, it does not mean that they will necessarily feel happy or confident in applying it in practice. Rapp, Saleebey and Sullivan (2008) offer six standards for judging what constitutes a strengths-based approach. Practitioners may like to use the following list to consider their own practice. The standards include:

Goal orientation: Strengths-based practice is goal oriented. The central and most crucial element of any approach is the extent to which people themselves set goals they would like to achieve in their lives.
Strengths assessment: The primary focus is not on problems or deficits, and the individual is supported to recognise the inherent resources they have at their disposal which they can use to counteract any difficulty or condition.
Resources from the environment: Strengths proponents believe that in every environment there are individuals, associations, groups and institutions who have something to give, that others may find useful, and that it may be the practitioner's role to enable links to these resources.
Explicit methods are used for identifying client and environmental strengths for goal attainment: These methods will be different for each of the strengths-based approaches. For example, in solution-focused therapy clients will be assisted to set goals before the identification of strengths, whilst in strengths-based case management, individuals will go through a specific 'strengths assessment'.
The relationship is hope-inducing: A strengths-based approach aims to increase the hopefulness of the client. Further, hope can be realised through strengthened relationships with people, communities and culture.
Meaningful choice: Strengths proponents highlight a collaborative stance where people are experts in their own lives and the practitioner's role is to increase and explain choices and encourage people to make their own decisions and informed choices.

Different types of approaches

Strengths-based approaches can work on a number of different levels - from individuals, associations and organisations right through to communities (Foot and Hopkins, 2010). There are rapidly burgeoning methods of practice being developed that are related to, and build upon, the fundamental building blocks of the strengths perspective. Some of these methods can and will be used alongside others, and some may be used in isolation. The focus of this insight is to better understand the use of a strengths perspective for transforming relationships between practitioners and people who are supported by services. The Insight will provide an overview of the evidence of the methods that align most closely to this focus, and will present selected illustrative examples.

Solution Focused Therapy (SFT) focuses on what people want to achieve rather than on the problem(s) that made them seek help. Encouraging people who are supported by services to focus on determining their own pathways and solutions to reach their goals can lead to dramatically different actions and thoughts than when pursuing answers to problems. In fact, research has shown that there is less than 5% correlation between goals related to problems and goals related to solutions (deShazer, 2004). As a consequence, the approach is centred on future aspirations and concentrates attention on 'life without the problem'.

SFT (and Solution Focused Brief Therapy (SFBT)) has been used in family service and mental health settings, in public social services and child welfare, in prisons and residential treatment centres and in schools and hospitals (Miller, Hubble and Duncan, 1996).

Strengths-Based Case Management combines a focus on individual's strengths with three other principles: promoting the use of informal supportive networks; offering assertive community involvement by case managers; and emphasising the relationship between the client and case manager. It is an approach that helps participants achieve specific desired outcomes.

Implementation of Strengths-Based Case Management has been attempted in a variety of fields such as substance abuse, mental health, school counselling, older people and children and young people and families (Rapp, 2008).

Narrative has been used by practitioners to help elucidate strengths of individuals and communities. Practitioners using this approach assume that hidden inside any 'problem' narrative is a story of strength and resilience. This will often require re-framing of the situation to highlight any unique instances of strengths into a story of resilience.

The practice of narrative is founded on the principle that people live their lives by stories or narratives that they have created through their experiences, and which then serve to shape their further life experience. Practitioners using this approach will often never deal directly with the problem being presented, but will find ways to strengthen the ability of the person to be resilient in the face of the problem, thereby reducing it. A key part of this approach is recognising that some people may think of a problem as an integral part of their character. Separating this problem from the person by externalising it allows them to begin to deal with it in a constructive way (Epston and White, 1992).

Family support services are frequently thought of as at the opposite end of the spectrum from child protection and are often equated with preventative services offered to families before their difficulties become too severe. The aims of family support include: responding in a supportive manner to families where children's welfare is under threat, reducing risk to children by enhancing family life and developing existing strengths of parents. Practitioners using this approach believe that strengths-based practice benefits families by influencing their engagement in the program, by increasing family efficacy and empowerment and by enhancing their social support networks (Green, McAllister and Tarte, 2004).

The evidence about what works

Although strength-based approaches offer an appealing alternative to traditional expert, deficit-based models, the evidence about the effectiveness of these practices is just beginning to emerge. As recently as 2009, there has been comment about the apparent dearth of research evaluating the efficacy of strengths-based practice of any kind (Lietz, 2009). Further, the evidence for strengths-based approaches is difficult to synthesise because of the different populations and problem areas that are examined in the literature. Emerging outcomes will be listed here, however, practitioners should note, that to date, there is not a strong evidence base for some strengths-based approaches.

Improving social connections

By building on the skills of local people, the power of local associations and the supportive functions of local institutions and services, strengths-based community development approaches draw upon existing strengths to build stronger, more sustainable communities. Researchers have found that by encouraging pride in achievements and a realisation of what people have to contribute, communities generate increased confidence in their ability to be producers not recipients of development (Foot and Hopkins, 2010).

Similarly, Gilchrist (2009) argues the importance and value of building networks within communities that results in individual, families and the wider community building a 'resilience' which leads to a sense of well-being and greater quality of life. 'Go Well' is one example of a research and learning programme that uses an assets approach to investigate the impact of investment in housing, regeneration and neighbourhood renewal on the health and well-being of individuals, families and communities over a ten-year period (Scottish Government, 2008b). Preliminary findings report increases in social harmony community empowerment and adult employment (Mclean, 2011).

On an individual level, strengths-based case managers often build on family and community interactions and knowledge. This practice is based on the recognition that networks often have more influence over an individual reaching a goal than any external person, including the case manager. Proponents of this model assert that people within social networks can provide unparalleled insight into the strengths, talents and challenges of a loved one, as well as advice about how best to connect with that individual. Family justice research using this model has shown to reduce drug use, lower rates of arrest and conviction and improve higher levels of social functioning (Shapiro, 1996).

Enhancing well-being

Empirical research suggests that strengths-based interventions have a positive psychological impact, particularly in enhancing individual well-being through development of hope. In a pilot study of people with serious mental health issues, people were asked to identify the factors that they saw as critical to recovery. The most important elements identified included the ability to have hope, as well as developing trust in one's own thoughts and judgments (Ralph, Lambric and Steele, 1996). One of the aims of strengths-based practice is to enable people to look beyond their immediate and real problems and dare to conceive a future that inspires them, providing hope that things can improve. Strength-based approaches are shown to be effective in developing and maintaining hope in individuals, and consequently many studies cite evidence for enhanced well-being (Smock, Weltchler, McCollum et al, 2008). Through having high expectations for individuals, strengths-based practitioners create a climate of optimism, hope, and possibility, which has been shown to have successful outcomes, particularly in work with families (Hopps, Pinderhughes, and Shankar, 1995).

Much strengths-based practice has an internal component, which is therapeutic in nature, and which involves locating, articulating and building upon individual's assets or capabilities. It also aims to assist with finding solutions for current problems based on currently available resources. Working to enhance an individual's awareness and understanding of their own strengths and capabilities has been shown to promote an increased sense of well-being (Park and Peterson, 2009). Furthermore, there is evidence that the use of personal narratives adds to the process of a positive re-framing of personal identity for people who use mental health services (Altenberger and Mackay, 2006).

Children, young people and families

There is emerging evidence of the use of strengths-based approaches with children, young people and families. The literature has identified an association between personal strengths in young people and academic success, self-determination and life satisfaction (Park and Peterson, 2006; Arnold et al, 2007; Lounsbury et al, 2009). Early and Glenmaye (2000) found that the use of the strengths perspective in families not only helped the family identify resources for coping, but also helped them use existing strengths to sustain hope and a sense of purpose by setting and achieving goals in line with their personal aspirations, capabilities, and visions of a possible life. Similarly, MacLeod and Nelson (2000), in a review of 56 programmes, found evidence to support the view that an empowerment approach is critical in interventions for vulnerable families. A strengths perspective shows how the practitioner can work positively towards partnership, by building on what parents already possess.

Seagram (1997) also found positive effects of solution-focused therapy undertaken by adolescents who had offended. Young people who had received therapy recorded significantly more optimism for the future, greater empathy and higher confidence in their ability to make changes in their lives. This highlights that eliciting and reinforcing a person's belief in their ability to successfully achieve a goal is a useful component of change.

Furthermore, a recent review of the use of Solution Focused Brief Therapy with children and families has suggested its effectiveness in asserting improvements in children's externalising behavior problems such as aggression, and children's internalisng problems such as anxiety and depression (Woods et al, 2011). However, the researchers of this review do caution at the limitations of the emerging evidence base with this group of people and state clearly that the evidence of effectiveness of solution focused brief therapy is insufficient to 'provide a mandate for its general use to facilitate positive change in parenting where children are considered to be suffering or likely to suffer significant harm' (Woods et al, 2011).

Improving retention in treatment programmes for those who misuse substances

Some empirical analyses have begun to suggest that the value of strengths-based approaches may lie in encouraging people to stay involved in treatment programmes, most notably for those with substance misuse problems. For instance, Siegal and colleagues looked at 632 people with substance abuse issues and found that providing strengths-based case management was associated with retention in aftercare treatment. Additionally, in a follow-up study, a relationship between case management, improved retention and severity of drug use was found in the same group, as well as improved employability outcomes (Rapp et al, 1998). However, the relationship between SBCM and improved outcomes was not direct, but mediated by the apparent ability of strengths-based case managers to encourage retention in aftercare.

In a review of individuals participating in Strengths Based Case Management, people also identified feeling free to talk about both strengths and weaknesses as important for helping them to set goals that they wanted to achieve and to make changes to their lives (Brun and Rapp, 2001). As such, researchers have postulated that the value of setting self-defined goals may simply be that they are more likely to be completed, as the individuals themselves have been involved in their development.

As with other client groups, many of the positive outcomes are often attributed to the development of positive relationships between those being supported and those providing support, which is a finding similar to most therapeutic effects compared to not treatment (Lambert and Bergin, 1994).

Implications for practice

There are dangers of practitioners from any agency polarising their practice into either 'risk assessment' or 'strengths-based approaches'. What may be in most people's interests is to develop approaches that look at the whole picture of a person's life. There is nothing in the strengths approach that instructs the discounting of the problems of life that people bring. In fact, the values of social work - which emphasise service user choice and empowerment - are consistent with those of a strengths-based approach. As Graybeal (2001) explains, 'the identification of strengths is not the antithesis of the identification of problems. Instead, it is a large part of the solution' (p234). In reality, therefore, both approaches are vitally important despite evidence suggesting that further work would be useful to redress the balance between the more dominant deficits approach and the emerging and less well known and understood strengths perspective.

Assessment

Strengths proponents believe that anything that assists an individual in dealing with the challenges of life should be regarded as a strength. Strengths will vary from person to person and, as such, it can be difficult to draw up an exhaustive list of strengths. Many researchers note that assessment tools in the field are still too often focused on deficits and inadequacies, and whilst there have been significant efforts to create and use assessment tools which incorporate strengths elements (Cowger and Snively, 2002; Early, 2001; Saleebey, 2001), these are still in the minority.

There are numerous guidelines to assist practitioners undertaking assessment and although they invariably differ in content, their commonalities often include the authors emphasis on the reality of the client, and the view that there should be a dialogue and partnership between them and the practitioner. It follows then that assessment should be couched in a broader dialogue that includes:

...meaningful questions that will combat the relentless pursuit of pathology, and ones that will help discover hidden strengths that contain the seeds to construct solutions to otherwise unsolvable problems (Graybeal, 2001, p.235)

Tools such as the ROPES (identifying: Resources, Opportunities, Possibilities, Exceptions, and Solutions) (Graybeal, 2001) model has been developed to guide practitioners in a broader process of continually drawing on strengths. Using frameworks focused on strengths and weaknesses encourages a holistic and balanced assessment of the strengths and problems of an individual within a specific situation.

Practitioner role

Current policy and legislative developments in Scotland have increasingly focused on working collaboratively with people to exercise choice and control over any support they may need. For many staff and professionals this represents a new way of working, and training and skills development will be required. Relationships are the cornerstone of this approach, as Davis puts it:

Regardless of the theories you have been trained in or the therapeutic tools you use with the persons who come to you for help, the only thing we know for sure is that the quality of the relationship between the person receiving or seeking help and the person offering help is a key to what kinds of outcomes are achieved (Davis, 1996, p. 423).

The experience of working in a strengths-based way may be difficult for practitioners, particularly because they may need to re-examine the way they work to being more focused on the future than on the past, to focus on strengths instead of weaknesses and from thinking about problems to considering solutions. Some emerging evidence suggests that this demonstrates the need to build the personal resilience of staff to a high level (C4EO, 2011).

The role of the professional becomes less about being a 'fixer' of problems and more about being a co-facilitator of solutions. This involves recognising that being professional does not always mean having all the answers and that in opening up discussions with individuals, an opportunity is created for them to contribute (Boyle et al, 2010). Seeing practitioners learn alongside individuals and reflecting on practice together can have a positive and lasting effect on service development (O'Neil, 2003). A facilitator will actively recognise and engage the things people are able to do or are interested in. In doing so, they will naturally focus on the things that are working well to create positive experiences driven by the person's intrinsic goals and aspirations. Therefore, a strengths-based approach is not simply about different tools or methods that are used with people who use services; it is about different concepts, structures and relationships that we build in our support services.

References

Altenberger I and Mackay R (2008) What matters with personal narratives?: An exploration as to how personal narratives are used in the promotion of recovery and social inclusion by mental health service users in Scotland (PDF)
Antonovsky, A (1987) Unraveling the mystery of health - How people manage stress and stay well, San Francisco: Jossey-Bass Publishers
Arnold EM, et al (2007) Strengths-based case management: Implementation with high-risk youth, Families in Society-The Journal of Contemporary Social Services, 88 (1), 86-94
Badenoch D (2006) Nice therapist, shame about the symptoms
Berg CJ (2009) A comprehensive framework for conducting client assessments: Highlighting strengths, environmental factors and hope, Journal of Practical Consulting, 3 (2), 9-13
Boyle D, Slay J and Stephens L (2010) Public services inside out: Putting co-production into practice, London: NESTA
Brun and Rapp (2001) Strengths-based case management: Individuals' perspectives on strengths and the case manager relationship, Social Work 46(3), 278-88
C4EO (2011) Participle: Swindon Family LIFE.
Cowger CD and Snively CA (2002) Assessing client strengths: Individual, family, and community empowerment, in D. Saleebey, The strengths perspective in social work practice (3rd ed),106-123,Boston: Allyn and Bacon
Duncan, B L and Miller S D (2000) The Heroic Client: Doing Client-Directed Outcome-Informed Therapy, San Francisco: Jossey-Bass
Early TJ (2001) Measures for practice with families from a strengths perspective, Families in Society: The Journal of Contemporary Human Services, 82, 225-232
Early TJ and Glenmaye LF (2000) Valuing families: Social work practice with families from a strengths perspective, Social Work, 45, 118-130
Epston D and White M (1992) Experience, contradiction, narrative and imagination: Selected papers of David Epston and Michael White, 1989-1991, Adelaide, Australia: Dulwich Centre
Foot J and Hopkins T (2010) A glass half full: How an asset approach can improve community health and wellbeing, London: Improvement and Development Agency
Gilchrist A (2009) The well-connected community: a networking approach to community development, Bristol: Policy Press
Graybeal C (2001) Strengths-based social work assessment: Transforming the dominant paradigm, Families in Society: The Journal of Contemporary Human Services, 82, 233-242
Green BL, McAllister CL and Tarte JM (2004) The strengths-based practices inventory: A tool for measuring strengths-based service delivery in early childhood and family support programs, Families in Society: The Journal of Contemporary Social Services 85 (3), 326- 335
Hook A and Andrews B (2005) The relationship of non-disclosure in therapy to shame and depression, British Journal of Clinical Psychology, 44, 425-438
Hopps J, Pinderhughes E and Shankar R (1995) The power to care: Clinical practice effectiveness with overwhelmed clients, in Early TJ and Glenmaye LF (2000) Valuing families: Social work practice with families from a strengths perspective, Social Work, 45, 118-130
Kretzmann JP and McKnight JL (1993) Building communities from the inside out: A path toward finding and mobilizing a community's assets, Evanston, IL: Kretzmann and McKnight
Lietz C (2009) Establishing evidence for strengths-based interventions? Reflections from social work's research conference, Social Work, 54(1), 85-87
Lounsbury JW, et al (2009) An investigation of character strengths in relation to the academic success of college students, Individual Differences Research, 7(1), 52-69.
Macleod J and Nelson G (2000) Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review, Child Abuse and Neglect, 24 (9), 1127-49
Mathie A and Cunningham G (2002) From clients to citizens: Asset based community development as a strategy from community driven development, The Cody International Institute, Occasional Paper Series 4
McLean J (2011) Asset based approaches for health improvement: redressing the balance, Glasgow: Glasgow Centre for Population Health
McMillen JC, Morris L and Sherraden M (2004) Ending social work's grudge match: Problems versus strengths, Families in Society: The Journal of Contemporary Social Services, 85(3), 317-325
Morgan A and Ziglio E (2007) Revitalising the evidence base for public health: An assets model, International Journal of Health Promotion and Education, Supplement 2,17-22
O'Neil D (2003) Clients as researchers: The benefits of strengths-based research, in Munford R and Sanders J (Eds) Making a difference in families: research that creates change (113-129) Sydney, Australia: Allen & Unwin
Park N and Peterson C (2006) Moral competence and character strengths among adolescents: The development and validation of the Values in Action Inventory of Strengths for Youth, Journal of Adolescence, 29, 891-910
Petersen C and Seligman MEP (2004) Character strengths and virtues: A handbook of classification, Oxford: Oxford University Press
Ralph RO, Lambric TM and Steele RB (1996) Recovery issues in a consumer developed evaluation of the mental health system. Presentation at 6th Annual Mental Health Services Research and Evaluation Conference, Arlington, VA, February, 1-13
Rapp C, Saleebey D and Sullivan PW (2008) The future of strengths-based social work practice, in Saleebey D (ed) (2006) The strengths perspective in social work practice, (4th Ed) Boston: Pearson Education
Rapp RC, et al (1998) Predicting post-primary treatment services and drug use outcome: A multivariate analysis, American Journal of Drug and Alcohol Abuse, 24, 603-615
Seagram B C (1997) The efficacy of solution-focused therapy with young offenders. Unpublished doctoral dissertation, York University, New York, Ontario, in Kim JS (2008) Examining the effectiveness of Solution Focused Brief Therapy: A meta-analysis, Research on Social Work Practice, 18(2), 107-116
Saleebey D (ed) (2001) Practicing the strengths perspective: Everyday tools and resources, Families in Society: The Journal of Contemporary Human Services, 82, 221-222
Saleebey D (ed) (2006) The strengths perspective in social work practice, (4th Ed) Boston: Pearson Education
Scottish Government (2008a) Equally well. Report of the Ministerial Task Force on Health Inequalities, Scottish Government, Edinburgh
Scottish Government (2008b) "Gaunyersel" The self management strategy for long term conditions in Scotland
Scottish Government (2010a) Self-directed support: A national strategy for Scotland. A 10 year strategy for self-directed support in Scotland
Scottish Government (2010b) Health in Scotland, 2009: Time for change. Annual report of the Chief Medical Officer, Edinburgh, Scottish Government
Shapiro C, Meyers A and Toner C (undated) Family justice clinical guide (PDF)
Siegel HA, et al (1996) Enhancing substance abuse treatment with case management: Its impact on employment, Journal of Substance Misuse Treatment, 13 (2), 93-98
Smock SA, et al (2008) Solution-focused group therapy for Level I substance abusers, Journal of Marital and Family Therapy, 34 (1), 107-120
Staudt M, Howard MO and Drake B (2001) The operationalization, implementation and effectiveness of the strengths perspective: A review of empirical studies, Journal of Social Service Research, 27(3), 1-21
White M (1992) Deconstruction and therapy, in Epston D and White M (1992) Experience, contradiction, narrative and imagination: selected papers of David Epston and Michael White, 1989-1991, Adelaide, Australia: Dulwich Centre
Woods K, et al (2011) Systematic review of solution focused brief therapy (SFBT) with children and families, Nottingham: DFE Publications

Acknowledgements

This Insight was reviewed by Fiona Garven (Scottish Community Development Centre), John Davis (Edinburgh University), Neil Macleod (Scottish Social Services Council), Helen Albutt (NHS Education for Scotland), Murray Lough (NHS Education for Scotland), Peter Ashe (NHS Scotland), Coryn Barclay (Fife Council), Steven Marwick (Evaluation Support Scotland).

Stenting of vessels of the lower extremities in the Innovative Vascular Center - angioplasty of the lower leg

Stenting of the arteries of the lower extremities is a treatment method based on strengthening the vascular wall with a special metal structure - a stent. Critical ischemia and gangrene of the lower extremities have long been treated only with open bypass surgery. With all the positive qualities, shunting has one drawback - it is a large open operation with incisions to access the vessels. This creates risks of complications associated with large interventions in patients with gangrene. Endovascular methods have made it possible to effectively treat critical ischemia in patients with concomitant lesions of the coronary, renal and carotid arteries of the brain. Vein stenting opens up new perspectives in the treatment of post-thrombotic venous disease. nine0003

The development of medical technologies has made it possible to minimize surgical trauma with the help of endovascular interventions through a skin puncture and without incisions. The main endovascular operations are angioplasty of the lower extremities and the installation of stents in the vessel. The meaning of vascular angioplasty is to inflate a narrowed or clogged segment with a special balloon passed through a thin conductor. After angioplasty, a special metal mesh - a stent - can be installed in the lumen of the restored vessel to support the wall. Historically, laser angioplasty was used to destroy plaque in vessels, but it has given way to new, advanced endovascular instruments. There are many medical institutions in Moscow that have extensive experience in vascular stenting. nine0003

Endovascular technologies in the Innovative Vascular Center

The main mission of our clinic is the diagnosis and treatment of critical limb ischemia and gangrene, deep vein pathology. We strive to use the latest approaches to solve this problem. Since 2011, the methods of endovascular surgery for critical ischemia have been introduced into the practice of our vascular surgeons. Noting the advantages and consequences of the endovascular approach, every year we expand the possibilities of our clinic in the application of these methods. Feedback from our vascular surgeons allows us to improve the design of stents and balloons for treatment. nine0003

The role of minimally invasive technologies is growing - now more than 50% of patients with critical ischemia and gangrene are operated on endovascularly, and even more than 40% use a hybrid approach. This is shunting with angioplasty and stenting of the vessels of the lower extremities. The Innovative Vascular Center is a clinic that performs more than 500 angioplasty and lower limb stenting operations per year at a reasonable price and has excellent feedback from patients.

The possibilities of endovascular vascular surgery are developing in tandem with the creation of innovative treatment tools, so in our practice, operations through a puncture are increasingly replacing open interventions. The use of hybrid technologies in the treatment of arterial diseases reduces the negative consequences of each surgical practice. In open operations, there is a risk of infectious complications, at the same time, the use of a combination of open and endovascular surgery reduces such consequences to zero. nine0003

Types of stents

Self-expanding stents are preferred for extended lesions, tortuous vessels, and in places of expected external influence - folds and twists. They are ideal for femoropopliteal lesions but are expensive. Such stents are made of shape memory metal and occupy a free lumen when deployed. For a better fit, the stents are further inflated with a balloon after insertion.

Balloon expandable stents are recommended for severe vessel wall calcification as seen in diabetes mellitus. They are suitable for perfectly precise positioning and do not move when installed. Special stents with high radial force are used for deep vein stenting. nine0003

Balloons and drug-eluting stents come from coronary angioplasty and can be used for revision surgery on the arteries of the leg. They are less prone to neointimal overgrowth, but have a higher cost. For angioplasty and stenting of the superficial femoral artery, special stents are used that can withstand an increased load. Prices for angioplasty of the lower extremities largely depend on the choice of instrument and its manufacturer.

Stent preparation

Before performing an angioplasty of the vessels of the lower extremities, the patient is examined for vascular lesions, risks of complications. A complex of laboratory examinations before the operation and a coagulogram should be performed. Considering the load of the patient with drugs against the formation of blood clots, it is necessary to exclude possible sources of bleeding (gastric ulcer, bleeding hemorrhoids).

On the eve of the intervention, a mild sedative is administered to allow the patient to sleep well and not be nervous. Before the operation, the patient is shaved the place of the intended access. In the preoperative room, a nurse will place a urinary catheter and an intravenous infusion needle. In the operating room, a blood pressure cuff is applied to the upper arm and sensors for continuous ECG recording are fixed on the chest. nine0003

Stent Anesthesia

Most endovascular angioplasty procedures and lower extremity stenting are done with moderate intravenous sedation and local anesthesia at the access site. Mandatory monitoring of blood pressure, electrocardiogram and blood oxygen saturation (pulse oximetry). In case of unforeseen complications, the operating room has a breathing apparatus and a defibrillator. If the operation is performed for critical ischemia, then for a comfortable position of the patient, epidural anesthesia is performed (introduction of an anesthetic drug through a catheter into the spinal region). nine0003

How is angioplasty of the vessels of the lower extremities performed?

For surgical intervention on the arteries of the lower extremities, the patient is placed in a position lying on his back with his arms at his sides. If shoulder access is expected through the antecubital fossa, then the arm is retracted 45-90º from the patient for ease of puncture. The most commonly used approach is through the femoral artery, but retrograde access through the vessels on the foot is also possible.

Percutaneous balloon angioplasty of the lower extremities begins with access to the vessel by pulsation, and if it is absent, then the puncture is performed by anatomical landmarks, but in our clinic ultrasound scanning in B-mode is used for access. After the needle enters the vessel, a thin conductor is passed through which a special tube is installed - an introducer with a valve at the end and the possibility of washing. Then a contrast injection is performed - angiography to clarify the tactics of the operation. The conductor is led to the place of narrowing, overcomes this narrowing and is carried further. After passing through all the constrictions, a balloon is passed through the conductor, which is inflated and models the lumen of the vessel (angioplasty). After that, a control angiography is performed, and if a dissection of the artery wall is detected, then a stent of a suitable diameter must be installed in this place. nine0003

Types of angioplasty

Subintimal balloon angioplasty of vessels - the conductor is inserted under the altered inner wall (intima) of the vessel and then goes into the free lumen.
Intraluminal angioplasty is a type of intervention when the guidewire passes through the natural lumen of the artery, slipping through narrowed and blocked areas.
In laser angioplasty, an atherosclerotic plaque is burned with a special laser catheter, which is very expensive. nine0042

Balloon angioplasty of the arteries of the lower extremities without stenting is recommended for the treatment of lesions of the lower leg. It is imperative to stent the iliac arteries, as the frequency of re-narrowing (restenosis) without a stent is very high. Stenting of the lower extremities allows remodeling the lumen of the artery and providing better distant patency.

After angioplasty and stenting, a follow-up angiography is mandatory to evaluate the result. nine0003

Possible complications

Complications after balloon angioplasty of the arteries of the lower extremities usually develop during the intervention and should be immediately eliminated. Ways against these complications are available in the arsenal of vascular surgeons. The following complications are most often observed:

Bleeding from the access site (hematoma or pseudoaneurysm) - most often occurs when the patient violates bed rest. Sometimes requires open access to eliminate the source of bleeding. nine0042
Puncture site infection is a very rare complication. It can develop with severe purulent-destructive processes on the lower limb. It needs to be treated with antibiotics. If necessary, open the purulent focus.
Contrast kidney damage is a rare complication of contrast media.
Dissection (dissection) of the artery - sometimes seen with complex lesions and attempts at subintimal passage. Most often, it can be eliminated by installing a stent. nine0042
Blockage of the arterial bed by pieces of plaque - can be determined by control angiography.
Fracture of the stent in the places of its bending is a late complication associated with mechanical stress on the metal.
Re-narrowing at the stent insertion site (restenosis) is the process of overgrowth of the lumen of the stented segment.
Rupture of the artery is a complication that develops due to excessive inflation of the balloon in a sharply calcified vessel. Detected during follow-up angiography. It is often possible to stabilize the situation with a long exposure of the balloon, it may require the installation of a stent graft or open surgery. nine0042
Spasm of the arteries - a reaction to the ballooning of the vessel. Occurs in 10% of procedures. To eliminate the spasm, drugs (papaverine, nitroglycerin) can be administered.

The frequency of all complications is no more than 5% of all procedures performed, and they are usually eliminated in a timely manner during the intervention.

Follow-up after angioplasty and stenting

Our clinic has adopted a scheme for managing patients after surgery against complications of angioplasty and stenting of the peripheral arteries of the lower extremities:

For best results, dual antiplatelet therapy can be given, including Plavix and aspirin. Drug prophylaxis plays an important role in the long-term results of the intervention, the general condition and life expectancy of patients.
The first examination should be done in the first 2 weeks of the postoperative period with obligatory ultrasound of the peripheral arteries.
The next examinations are carried out in a few months. For patients who do not live in Moscow, it is enough to come for an appointment and examination once a year. nine0042
A year after the surgical treatment, the doctor will definitely prescribe MSCT angiography of the legs.

Balloon angioplasty and stenting of the arteries of the lower extremities is an effective method of restoring blood flow in most occlusive lesions except the popliteal artery. In its immediate results, this method is not inferior to open bypass surgery, if carried out according to strict indications. The advantage of endovascular surgery is low trauma, no pain, the possibility of repeated interventions, as well as a lower risk to life. In their feedback, patients note the easy tolerability of endovascular technologies compared to open surgeries. nine0003

As the instruments for angioplasty and stenting improve, minimally invasive interventions are becoming increasingly important in the management of patients with critical ischemia and gangrene. The price of consumables is decreasing and new advanced devices are appearing. More and more clinics in Moscow are introducing these methods into the practice of treatment instead of amputation.

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