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

Abstract

Background: The frequency and clinical impact of Sudden Gains—large symptom improvements during a single between-session interval—in psychotherapy for depression have been well established. However, there have been relatively few efforts to identify the processes that lead to sudden gains.Aim: To explore therapy processes associated with sudden gains in cognitive therapy for depression by examining changes in the sessions surrounding the gains, and the session preceding the gain in particular.Methods: Using ratings of video-recordings (n = 36), we assessed the content, frequency and magnitude of within-session cognitive-, behavioral-, and interpersonal change, as well as the quality of the therapeutic alliance in the session prior to the gain (pre-gain session), the session after the gain (post-gain session) and a control session. After that, we contrasted scores in the pre-gain session with those in the control session. In addition, we examined changes that occurred between the pre- and post-gain session (between-session changes) and explored patients' attributions of change.Results: Although not statistically significant, within-session changes were more frequent and stronger in the pre-gain session compared to the control session. The largest difference between the pre-gain and control session was found in the behavioral domain, and reached the level of trend-significance. There were more, and more impactful between-session changes in the interval during which the gain occurred as compared to a control interval. Exploratory analysis of attributions of change revealed eight subcategories, all corresponding with the cognitive-, behavioral- and interpersonal- domain. The quality of the therapeutic alliance was high and almost identical in all sessions.Conclusion: In spite of its small sample size, our study provides relevant descriptive information about potential precipitants of, themes related to, and attributions given for sudden gains. Furthermore, our study provides clear suggestions for future research. A better understanding of session content in the sessions surrounding sudden gains may provide insight into the mechanisms of change in psychotherapy, hereby suggesting treatment-enhancing strategies. We encourage researchers to conduct research that could clarify the nature of these mechanisms, and believe the methods used in this study could serve as a framework for further work in this area.

Intraindividual variability and emotional change as predictors of sudden gains in imagery rescripting and EMDR for PTSD in adult survivors of childhood abuse

“…Together with the temporal pattern and newer findings (see Lemmens et al, 2021;O'Mahen et al, 2021), this contradicts the assumption of sudden gains being merely a form of random fluctuations and suggests that they mark important and meaningful points in the change process.…”

“…In sum, these findings show that guilt, shame and disgust might be involved in the occurrence of sudden gains, or in sustainment of gains and/or in facilitating further improvement during treatment. Together with the temporal pattern and newer findings (see Lemmens et al, 2021; O'Mahen et al, 2021), this contradicts the assumption of sudden gains being merely a form of random fluctuations and suggests that they mark important and meaningful points in the change process.…”

Sudden gains in therapist-guided versus self-guided online treatments for anxiety or depression.

“…In contrast, the prevalence of sudden gains in depressive symptoms in the present study is lower than has been reported previously. In a small clinical trial of online treatment for postnatal depression, O’Mahen et al (2017) found that 51% of participants experienced a sudden gain, and estimates of sudden gain prevalence range from 25% to 54% during face-to-face treatment (e.g., Abel et al, 2016; Lemmens et al, 2021). However, only 19% of participants experienced a sudden gain throughout online treatment in the present study.…”

Paradoxical interventions: A meta-analysis.

“…Even though some immediate shifts in symptom presentation may occur (particularly in response to interventions like symptom prescription), this type of first-order change alone (symptom reduction) does not indicate that the paradox has been effective. However, paradigms that track rapid symptom change (from session to session) may be useful in tracking the effectiveness of PIs (Lemmens et al, 2021; Tang & DeRubeis, 1999). This suggestion is related to the systemic destabilization and reorientation that hopefully takes place during the implementation of a PI, consistent with Tang and DeRubeis’s (1999) thesis regarding sudden gains in psychotherapeutic process.…”