Participant characteristics
Twelve EPPIC clinicians (Mage=33.33 years, SD=8.39, range: 26-57; 66% female) were recruited from four disciplines: clinical psychology (n=7), psychiatry (n=2), mental health nursing (n=2), and occupational therapy (n=1). Three participants were investigators on research studies that addressed cognition in FEP. None of the participants had experience in research or clinical practice focusing on a cognitive strengths-based approach. The clinical experience of participants in an FEP-specific context ranged from 1 to 25 years (Mean=5.79 years, SD=6.6).
Thematic structure
Five over-arching themes were identified, with three containing sub-themes. A thematic map is shown in Figure 1. Using the semi-structured interview questions, no new themes emerged by the end of the twelve interviews.
Theme 1: Pro-strengths attitude despite unfamiliarity and minimal use
Clinicians generally held a positive stance toward strengths-based approaches in treatment. They believed it was important to consider young people's strengths and incorporate them into their practices: "If we're gonna… assess what's not going so well for the client, it's just as important to focus on and highlight what they're doing well" (P2). Most clinicians seemed to engage with broader strengths in their current work and many also indicated that the early psychosis service (EPPIC) endorsed a recovery-oriented strengths-focused approach. Nevertheless, most clinicians recognised the minimal application of strengths in current practice and believed there should be increased attention toward young people's strengths: "...there should be more focus on strengths, and… I think young people would really appreciate that" (P8); "Again, we probably just don't think about that [cognitive strengths] kind of enough" (P9).
Despite the positive attitudes toward strengths approaches broadly, conceptualising cognition through a strengths-based lens was difficult and unfamiliar to many clinicians: "like, how do we...is there a consistent way of conceptualising what [a] cognitive strength is?" (P5). The definitions were varied and consisted of multiple definitional frameworks [See Additional File 2]. Several clinicians defined cognitive strengths in relation to functional abilities: "whether they [young people] could sort of...make a well-informed decision" (P5); or whether young people can benefit from treatment, e.g., "whether they are able to engage in actual cognitive therapy or not" (P7).
Most clinicians recalled instances where they acknowledged young people’s character strengths (e.g., perseverance, resilience). Yet, they admitted that their involvement specifically with cognitive strengths was either minimal or non-existent. Those with minimal involvement did so indirectly when broadly considering other functional strengths: "I don't know that I would specifically home in on cognitive strengths...but, I guess, when I'm working with people, I would try to identify what their strengths are in any kind of field" (P3).
Theme 2: Default to a cognitive deficit lens
Clinicians frequently and inadvertently resorted to a deficit-focused perspective during their interviews. For some clinicians, this occurred immediately when they were asked about cognitive strengths:
"It's really that perspective taking, the stuff that I've noticed that they can struggle with, and then like as I'm saying all this, I notice that I'm talking about it from a deficits place still." (P11)
More commonly, an initial reference to strengths transitioned to deficits:
"So… time is important for vocational functioning. Like, knowing when to get to a certain place and have an idea of how long it's gonna take to get there. That sort of, I suppose, forward-thinking and problem-solving. Um, I know for a lot of the clients that I work with, a difficulty is not being able to problem-solve, particularly if they're using, like, public transport." (P2)
Some clinicians held a subtle deficit orientation by defining cognitive strengths as the resolution of a young person’s difficulties:
"… you know, using it [cognitive strengths] in your mental status… if someone is having difficulty keeping up with things in the session and that kind of stuff; but you know, you might reflect on those things improving if someone's getting better but it's still from a kind of deficit model rather than a strength model." (P6)
Several clinicians were aware of their own deficit focus and the deficit orientation of the FEP field in general: "I would probably think more of people's cognitive difficulties than cognitive strengths. Yeah, I think I probably would have more of a bias towards that" (P7). Several clinicians added that the medical model remained an integral part of assessment and treatment in FEP: "It's harder because I suppose when we do cognitive assessments, it's more sort of to look for deficits than strengths" (P2).
Theme 3: Potential benefits of a cognitive strengths approach
Enhancing Positive Self-Efficacy
Most clinicians believed that a cognitive strengths-based assessment and intervention could potentially enhance a young person's self-efficacy. For example, one participant suggested that self-awareness and directed use of cognitive strengths could improve a young person’s self-confidence:
"…well, they're really good at organising. Then you know, when they're – let's say at the school, that we sort of have programs where teachers can get them to do more sort of in-house sort of organisation for other people or activities. And that could really build on their self-confidence and self-esteem." (P5)
Other clinicians described positive effects on young people's sense of empowerment and agency:
"People would have...more of an awareness of areas that they can feel a sense of competency...and that can also then help with motivation… and a sense of agency because they've been able to think about the things that they can do." (P10)
Another participant similarly described cognitive strengths as a way for young people to, "...start taking charge of their own healthcare and feel empowered that way" and "use those strengths to get [young] people to make their own decisions...with their own lives" (P6).
This approach was thought to potentially help change the narrative around a young person’s treatment to incorporate their cognitive strengths:
"...if we can embed some of the strengths of that client with their cognition into sort of a story that we're developing with them, I think it helps sort of raise the awareness of what they're doing well." (P2)
Clinicians believed that helping young people change their clinical narrative may alleviate their self-stigmatisation and perceived defectiveness.
Harnessing cognitive strengths to improve engagement, the therapeutic alliance, and treatment
Most clinicians believed that utilising a cognitive strengths approach would resonate with young people's goals and priorities and therefore enhance engagement with the service:
"I think when you point out someone's strengths rather than pointing out their flaws and what we need to improve, and if you help them use their strengths, you know, you tend to get better engagement. You get better results because people feel empowered." (P6)
As such, clinicians commented that a cognitive strengths approach could enhance the therapeutic alliance, as they can acknowledge the young person’s attributes beyond their difficulties:
"I guess it would make them hopefully feel like we're not just viewing them as their difficulties or their problems..." (P7)
Clinicians also highlighted the benefit of developing a richer understanding of a young person's cognitive strengths. Awareness of cognitive strengths "could help with formulation and understanding the person" (P4) and subsequently inform how clinicians and young people can incorporate these strengths in their treatment: "…when you're starting to focus on recovery, then identifying strengths that you can use within the therapy… would be really helpful" (P3). This deeper understanding was also thought to assist them in determining what types of interventions would be possible or appropriate: "… it'll give an indication of someone's abilities, which will indicate what level of psychotherapy they're capable of doing at the moment" (P9). Thus, several clinicians believed that this knowledge could help them adopt the most suitable communication strategy when delivering treatment: "if you found that someone was better at communicating visually, then you might use drawings or diagrams more in your therapy” (P3). Clinicians also suggested that other professionals (e.g., teachers) can use this knowledge to maximise a young person's vocational and educational recovery.
Theme 4: Potential risks and barriers
Challenges of a cognitive strengths approach
Clinicians were concerned that a cognitive strengths approach could reduce attention toward deficits or acute needs. If therapeutic time was made available for assessing and working with cognitive strengths, clinicians may "end up not really focusing on what's not going so well" (P6) and "almost ignore the deficits" (P1). Similarly, focusing on cognitive strengths was thought to interfere with risk assessment or management of acute psychotic symptoms. Nevertheless, several clinicians believed that young people's difficulties would not be neglected given that the prevailing focus was on deficits.
Clinicians were further concerned that a cognitive strengths approach would engender unrealistic hope for young people. This could occur when few, or fewer than expected, cognitive strengths were found or where, "the strengths that you find may not be the strengths that young people want to have in their brain" (P8). Clinicians also indicated that false hope could arise if cognitive strengths identified during recovery regressed during relapse. Some clinicians felt that this situation could cause young people to experience a greater sense of loss: “and that might, if it didn’t go well, that might bring about a sense of hopelessness” (P9).
Clinicians were also concerned that focusing on cognitive strengths would risk invalidating young people’s concerns:
"If you talk too much about strengths, it can be perceived as dismissing, like, 'things are really shit for me right now and we're talking about what's...what I'm doing right'?" (P1).
Challenges within the FEP service context
Time and resource limitations were frequently highlighted as a barrier to cognitive strengths assessment and intervention. Most clinicians believed it would be difficult to implement new assessments with their current time constraints:
"I think a big factor for a lot of clinicians is the time constraints that holding an assessment sort of has on your demands" (P2); "The biggest thing is time, really." (P6)
Some clinicians were concerned about implementing a cognition-specific intervention, due to the variability in perspectives and experience in working with cognition across the early psychosis multidisciplinary teams. Others expressed related concerns that any new assessment would need to involve significant training of service staff. To address both the time and training/resourcing concerns, many clinicians indicated a preference for any cognitive strengths assessment to be outsourced to a specialist clinician or built into the service's intake processes.
Clinicians also raised concerns that additional cognitive strengths assessments would increase the 'assessment burden' on young people who attend the service. For example, if young people undergo "a good three or four assessments even before you kind of start the work properly" (P4), a requirement to complete a cognitive strengths assessment might make the person "feel like they're just doing these endless assessments" (P9).
Theme 5: Considerations for successful implementation
Considerations for young person and clinician 'buy-in'
Clinicians believed that clear communication of the rationale of a cognitive strengths assessment or intervention was essential to gain 'buy-in' from young people: "I think you'd have to explain it really, really well and it'd have to be quite transparent with why you're doing it, what it means, and why it could be beneficial" (P4). Clinicians urged that young people would need to believe that "there was something tangible at the end of it" (P9), "otherwise they won't do it, or won't agree to do it" (P8). Emphasising a clear benefit also addresses the time and resourcing issues identified previously: "[the assessment or intervention] has to be more valuable...than the thing that they're not doing" (P9) and thus, "It would need to be useful...like it would need to actually serve a proper function" (P4). To reduce young people's negative expectations from previous assessment experiences, several clinicians highlighted that the rationale should clearly state that the assessment "isn't about finding something that's wrong, it's about finding, you know, actually what you're good at" (P6).
Clarity in content and delivery of the assessment or intervention was deemed necessary for optimal engagement. Clinicians proposed avoiding jargon: "if we're going to stick with words like cognition and cognitive, you have to be able to also provide quick explanations of what those words mean" (P1); "I think as soon as you say cognitive strengths you've probably lost them a little bit" (P4). To address these issues, several clinicians suggested including scenarios or examples throughout assessment delivery, both to clarify meaning and to help young people resonate with assessment items:
"If they can draw on personal experiences somehow with a question that identifies oh, actually that was a strength to be able to do that, I think that would help personalise it rather than it being this kind of assessment of a list of strengths that they can't relate to I guess" (P10).
Several clinicians suggested using technology to enhance engagement: "iPad stuff – they're always more likely to be on board with" (P6) and "I think in particular for young people now… just the kind of paper copy versus like actually having an app where you can, you know, interact with an app I imagine would be a lot easier for them" (P10).
Finally, several clinicians emphasised that it was important to, "tell people you're going to be able to give them feedback" (P3) and that when provided it should be, "Quick feedback that's relevant" (P9) and in a usable form.
Suggested methods for assessing cognitive strengths
There was no consensus for a particular assessment method. Most clinicians suggested that young people would respond negatively to traditional forms of assessment (e.g., self-report questionnaire): "I think filling out any questionnaire, young people are sort of over it" (P6). Nevertheless, some clinicians believed that it would be difficult to objectively measure a young person's cognitive strengths without some form of standardised neuropsychological assessment. Thus, several clinicians accepted that traditional assessments might be suitable, but should be translated to a more youth-appropriate form.
Some clinicians stated that gathering information on cognitive strengths could occur as part of existing information gathering practices: "Maybe... it's more something that we just need to hold in mind and have it as part of our getting to know the young person as we move through the initial stages of working with them" (P7). However, some clinicians were concerned that assessing cognitive strengths without a formal structure could lead to inaccurate appraisals of strengths or that a deficit focus would be inadvertently adopted: "I mean at the moment, it's sort of ad hoc [appraisal of cognitive strengths], by what's sort of presenting in the room. Certainly, it's more ... more the deficits that come to people's attention" (P1).
Several clinicians advocated assessing cognitive strengths via a task-based process that focused on how people functioned while completing certain operations. Clinicians who supported this approach argued that it had more relevance to aiding a young person’s functional recovery:
"I think you get so much more out of doing a functional sort of based assessment with someone as opposed to sort of just, 'Here's a question, can I have an answer?' I think it's really ... a dynamic way of finding about um, how clients sort of operate in the day-to-day." (P2)
Others suggested a combined approach where information on cognitive strengths would be gathered from informants (e.g., family and schools), in addition to some form of self-assessment.