Are there any robust predictors of “sudden gainers,” and how is sustained improvement in treatment outcome achieved following a gain?

Abstract

Objective: It has been widely demonstrated that the process of change many patients undergo in therapy is not linear. Some patients benefit greatly from large sudden improvements, commonly referred to as "sudden gains." It is less clear whether certain baseline characteristics make patients more prone to displaying sudden gains, as well as what mechanisms are responsible for the lasting effects of sudden gains. Method: In a sample of 547 patients receiving treatment in an outpatient mental health clinic, a machine learning approach was used to search for potential predictors of sudden gains. A within-patient mediation model was used to investigate whether alliance serves as a mechanism underlying the sustained effect of sudden gains. Results: Twelve percent of patients showed sudden gains. Consistent with previous studies, no robust predictors of sudden gains were found, even when using an approach capable of evaluating the contributions of multiple predictors and their interactions. A significant within-patient mediation model was found, according to which sudden gains predict subsequent strengthening in alliance, which in turn predict subsequent improvement in life satisfaction and psychological dysfunction. These findings support the proposed theoretical framework whereby alliance is an important ingredient of an upward spiral that may results in sustained sudden gains. Conclusions: The findings provide first evidence of the presence of an ingredient responsible for the sustained effect of sudden gains, using a within-patient mediation model. The findings support the important role alliance may play in the consolidation and subsequent expansion of the effect of sudden gains. What is the public health significance of this article?Findings suggest that the alliance may act as an important ingredient in sustaining large sudden improvements (commonly referred to as "sudden gains") over time. The analyses support the conceptual model according to which sudden gains drive subsequent strengthening in alliance, which in turn serves to improve life satisfaction and psychological dysfunction.

A comparison of the effects of sudden gains and depression spikes on short- and long-term depressive symptoms in a randomized controlled trial of behavioral activation and cognitive behavioural therapy.

“…Similar to other studies, none of the baseline variables that we assessed were associated with sudden gain Hunnicutt-Ferguson et al, 2012;Shalom & Aderka, 2020;Zilcha-Mano et al, 2019) or depression spike status. It may be that initial client characteristics are a less robust predictor of whether a person will experience discontinuous change than what happens in therapy (Tang & DeRubeis, 1999).…”

“…Lastly, few studies have examined whether baseline client characteristics might be significant predictors of discontinuous change during treatment (Aderka et al, 2021; Hunnicutt-Ferguson et al, 2012; Zilcha-Mano et al, 2019). For example, individuals who enter treatment with greater behavioral activation or fewer dysfunctional attitudes might be able to better make use of BA or CBT, respectively (Cheavens et al, 2012), and this could induce discontinuous change.…”

Therapy Processes Associated With Sudden Gains in Cognitive Therapy for Depression: Exploring Therapeutic Changes in the Sessions Surrounding the Gains

“…Unfortunately, those data were not available. Alternatively, as suggested by Zilcha-Mano et al (4), it could also point toward alliance as an important ingredient of an upward spiral in which sudden gains lead to a further strengthening in alliance, which in turn predict further improvements in well-being, which in may result in sustained sudden gains.…”

“…Studies aimed at explaining why sudden gains occur have often focused on the predictive value of baseline characteristics (3). However, so far, no robust predictors of sudden gains have been identified, even in studies in which multiple predictors and their interactions were examined [e.g., (4)]. An explanation for this might lie in the strong association between sudden gains and treatment outcome, which suggests that this phenomenon is driven by important breakthroughs that occur during treatment that are difficult to predict using pre-treatment characteristics.…”

Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents

“…These results seem to imply that the mechanisms of SGs might differ between different treatment modalities. The role of the alliance in SGs has been further explored in a recent study by Zilcha-Mano et al (2019). According to their results, SGs seem to lead to subsequent strengthening of the alliance, which in turn predict improvements in life satisfaction and psychological functioning.…”