Sudden gains and deteriorations: Modeling the impact across outcomes with university counseling center clients.

OBJECTIVE: This study examines the longitudinal impact of sudden gains/deteriorations across the outcomes associated with the phase model. METHOD: In a sample of 16,657 clients who completed the Behavioral Health Measure-20, we identified sudden gains/deteriorations and employed multilevel piecewise analyses to assess their impact on subsequent treatment phases. RESULTS: We found that: (1) Following a sudden gain in the well-being outcome, the mean-level for the symptom outcome increased (meaning symptoms improved), and the rate of change decreased, (2) Following a sudden gain in the symptom outcome, the mean-level for the life functioning outcome increased, (3) Following a sudden deterioration in the well-being outcome, the mean-level and rate of change for the symptom outcome decreased, and (4) Following a sudden deterioration in the symptom outcome, the mean-level for the life functioning outcome decreased. CONCLUSIONS: These findings reveal that sudden gains/deteriorations function and occur at different rates across phases of change in psychotherapy.

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

Sudden gains, defined as large and stable improvements in symptom severity during psychological treatment, have consistently been found to be associated with better outcomes across treatments and diagnoses. Yet, insights on coherent predictors of sudden gains and on emotional changes around sudden gains in post-traumatic stress disorder (PTSD) are lacking. We aimed at replicating a measure of intraindividual variability as a predictor for sudden gains and testing its independence from change during treatment. Furthermore, we expected changes in emotions of guilt, shame and disgust prior to sudden gains to predict sudden gains. Data from a pre-registered randomized controlled trial (RCT) of eye-movement desensitization and reprocessing (emdr) and Imagery Rescripting (ImRs) for PTSD in 155 adult survivors of childhood abuse were used. Intraindividual variability of PTSD symptoms in both treatments did not predict sudden gains status and was not independent of change during treatment. In the EMDR condition, levels of shame during treatment predicted sudden gains and shame decreased shortly before a sudden gain in both treatments. Reductions in all emotions during sudden gains were significantly higher for participants with sudden gains than for comparable intervals in non-sudden gainers. Our findings do not support the predictive validity of intraindividual variability for sudden gains. The decrease of guilt, shame and disgust during sudden gains warrants further research on their role as a mechanism of treatment change for PTSD.

Sudden gains in PTSD symptoms and social functioning in cognitive processing therapy for posttraumatic stress disorder.

OBJECTIVE: Sudden gains (SGs) are rapid symptom improvements between two consecutive therapy sessions that predict treatment outcomes. This study investigated SGs in posttraumatic stress disorder (PTSD) symptoms, interpersonal relationship functioning, and social role functioning in Cognitive Processing Therapy (CPT). METHOD: Participants were 121 patients and 81 therapists involved in a parent randomized controlled hybrid implementation-effectiveness trial of CPT. Descriptive analyses examined the frequency and timing of different forms of SGs. Multilevel modeling examined the impact of the three SGs on outcomes. RESULTS: PTSD SGs occurred more often and at different sessions than SGs in facets of social functioning. Most individuals experienced only one form of SG and there were no significant clinical or demographic differences in those who had PTSD only SGs, social functioning only SGs, or both SGs. PTSD SGs and interpersonal relationship functioning SGs both predicted changes in PTSD symptoms and interpersonal difficulties over time, but not changes in social role functioning. SGs in social role functioning predicted all three forms of outcomes. CONCLUSIONS: The findings suggest that there are multiple forms of SGs in CPT beyond primary symptom changes that are predictive of patient outcomes. Clinicians should highlight various SGs that patients experience to further enhance outcomes.

Patterns of alliance development in cognitive behavioral therapy versus attention bias modification for social anxiety disorder: Sawtooth patterns and sudden gains.

OBJECTIVES: We examined patterns in alliance development in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). We focused on the occurrence of sawtooth patterns (increases within- and decreases between-sessions) and sudden gains and their association with outcome. METHODS: Clients received CBT (n = 33) or ABM (n = 17). Client-rated alliance was measured before and after each session. Self-reported and clinician-rated anxiety were measured weekly and monthly, respectively. RESULTS: The alliance increased in CBT in a sawtooth pattern and did not change in ABM. When examining individual clients, sawtooths were more common in CBT (61% clients) than in ABM (6%) and predicted worse outcome in CBT. Sudden gains were equally frequent (CBT, 18%; ABM, 18%) and did not predict outcome. CONCLUSION: The alliance in CBT is dynamic and important for outcome. Sawtooths are common in CBT and may mark worse outcome.

Sudden gains and treatment outcomes among depressed individuals in a partial hospitalization programme.

Sudden gains commonly occur among patients receiving psychotherapy for depression and have been found to consistently predict better treatment outcomes. However, the majority of prior research has examined sudden gains primarily in weekly or biweekly treatment settings. Individuals were divided into two groups: those who experienced at least one sudden gain and those who did not. Rates of sudden gain occurrence, pretreatment factors and posttreatment outcomes were examined between the two groups. Over 60% of this sample experienced at least one sudden gain, the majority of which occurred during the first 3 days of treatment. Sudden gains were associated with significantly lower baseline depression and anxiety severity. Patients who experienced sudden gains reported significantly greater improvement in depressive and anxiety symptoms, coping skills, functioning, positive mental health and well-being at treatment termination. This study was conducted in a single location with a relatively homogeneous sample. Due to a lack of follow-up data, we were unable to determine if treatment outcomes were sustained after treatment termination. The assessment timeline of the depressive symptoms differs between baseline and daily scales, which may have affected the number of observed sudden gains after the initial treatment day. The proportion of sudden gains in this study is higher than those found in outpatient settings, demonstrating that this phenomenon may commonly occur among depressed patients in acute treatment. These results suggest that the mechanisms by which sudden gains occur may be reinforced by daily, intensive treatment.

Two kinds of sudden gains in brief psychotherapy.

OBJECTIVE: Sudden gains (SGs) are known to predispose to good outcome in psychotherapy, especially in brief treatment. However, some SGs may be illusory, in the sense that they arise from measurement error in the context of gradual change. We examined change before, during, and after SGs that were either true or illusory. METHOD: In a sample of 1,867 university students treated with brief psychotherapy, we simulated session data as gradually changing score sequences, identified artifactual SGs therein, and utilized the simulated data to categorize actual participant SGs as either illusory or true. RESULTS: During treatment, participants with illusory SGs (N = 42) improved as much as did participants with true SGs (N = 67). Moreover, late in treatment participants with SGs and their matched controls improved at similar rates. True SGs were preceded by more distress and were larger than illusory SGs. Among participants with true SGs, very large SGs were more likely to reverse later in treatment. CONCLUSIONS: Relatively small SGs may reflect measurement error. When brief psychotherapy patients deteriorate early in treatment but then suddenly experience substantial improvement, little further change is to be expected.

Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive-behavioural therapy for severe health anxiety.

There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive-behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.

Working with emotion predicts sudden gains during experiential therapy for depression.

Objective: This study involves the first attempt to identify sudden gains in a sample of clients undergoing experiential therapy for depression while also investigating client and therapist change processes related to sudden gains.Method: Pre- and post-session Beck Depression Inventory, short form (BDI-SF) questionnaires were used to identify sudden gains and differentiate between in-session and between-session symptom changes in thirty-six client-therapist dyads. Archival videotape data of a sub-sample were coded using the Experiencing Scale, Classification of Affective Meaning States, and the Coding System for Therapist Focus.Results: The study revealed that 63.9% of clients experienced a sudden gain and the bulk of the total mean symptom decrease (74.9%) was found to occur within the session preceding the sudden gain. During this critical session, clients were more likely to display deepened experiencing (p < .01, η2 = .34), clients were more likely to express "primary adaptive emotions" (p < .05, r = .38), and therapists were found to be more likely to focus on unmet client needs (p < .01, d = .75).Conclusion: The majority of the sudden gain change occurs within session in experiential therapy, and primary adaptive emotions as well as addressing unmet needs are possible processes of sudden gains.

Predictors and consequences of sudden gains in transdiagnostic cognitive-behavioural therapy for anxiety disorders.

Sudden gains-substantial stable symptom improvements between consecutive therapy sessions-are a common phenomenon. As condensed points of change, examination of sudden gains can provide insight into mechanisms of therapeutic change. This study investigated the association between sudden gains and cognitive change, therapeutic alliance, and/or client engagement in transdiagnostic group cognitive-behavioural therapy for anxiety disorders. Of 58 treatment initiators, 21% (n = 12) exhibited a sudden gain. Consistent with previous research, sudden gainers demonstrated significantly greater pre- to post-treatment symptom improvement than non-sudden gainers. Observational coding of therapy sessions found that sudden gains were associated with elevated levels of cognitive change and client engagement in the pre-gain session, and elevated levels of cognitive change and therapeutic alliance in the post-gain session. However, these results varied by use of within- and between-subject control comparisons, highlighting the value using a dual control methodology. In context of previous research, the results on cognitive change replicate previous findings in depressive populations, and clarify mixed findings in anxiety populations. The results on therapeutic alliance replicate previous findings for the first time in an anxiety sample, although the between-subject control comparisons revealed complexity previously undetected. This study was also the first to investigate and thus establish the relation between client engagement and sudden gains.

An exploratory study of patients' sudden losses during outpatient CBT and therapists' experience of difficulties.

OBJECTIVE: Patients' sudden deterioration in symptomatology, also called sudden losses, is a rarely explored phenomenon. METHOD: Psychological distress of 1,763 patients treated by 140 therapists was monitored after every therapy session. Patient-reported outcome measures and patients' therapy satisfaction was assessed. Therapists rated their experience of difficulties for every patient repeatedly over the course of therapy. RESULTS: More than one-quarter of patients (26.5%) experienced at least one sudden loss during therapy. Patients with sudden losses did not differ significantly in psychotherapy outcome and therapy satisfaction from patients without sudden shifts. Therapists did not experience professional self-doubt more often when working with sudden loss patients. CONCLUSION: Sudden losses were not necessarily harmful for the outcome of psychotherapy and patients' global therapy satisfaction. The results suggest that sudden losses can be compensated over the course of treatment.

How to customize a bona fide psychotherapy for generalized anxiety disorder? A two-arms, patient blinded, ABAB crossed-therapist randomized clinical implementation trial design [IMPLEMENT 2.0].

BACKGROUND: Bona fide psychotherapy approaches are effective treatments for generalized anxiety disorder (GAD) compared to no-treatment conditions. Treatment manuals and protocols allow a relatively high degree of freedom for the way therapists implement these overall treatment packages and there is a systematic lack of knowledge on how therapists should customize these treatments. The present study experimentally examines two implementation strategies of customizing a bona fide psychotherapy approach based on a 16 session time-limited cognitive-behavioral therapy (CBT) protocol and their relation to the post-session and ultimate treatment outcomes. METHODS: This trial contrasts two different implementation strategies of how to customize the in-session structure of a manual-based CBT-protocol for GAD. The patients will be randomly assigned to two implementation conditions: (1) a systematic focus on subtle changes lasting from 7 to 20 min at the check-in phase of every psychotherapy session and (2) a state-of-the-art (SOTA) check-in phase lasting several minutes mainly focused on the session goals. Potential therapist effects will be examined based on an ABAB crossed-therapist design. Treatment outcomes will be assessed at the following times: post-session outcomes, treatment outcome at post assessment and 6- as well as 12-month follow-up. DISCUSSION: The proposed randomized clinical implementation trial addresses the clinically relevant question of how to customize a bona fide psychotherapy protocol experimentally contrasting two implementation strategies. Through the development and testing of the proposed implementation design, this trial has the potential to inform therapists about efficacious implementation strategies of how to customize a manual-based treatment protocol in respect to the timing of the in-session structure. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov ( NCT03079336 ) at March 14, 2017.

Brief report: sudden gains in cognitive-behavioral group therapy and group psychotherapy for social anxiety disorder among college students.

The present study examined sudden gains (SGs; large symptom improvements between adjacent treatment sessions) and its association with treatment outcome in a randomized-controlled trial comparing cognitive-behavioral group therapy (CBGT) versus group psychotherapy (GPT; designed to incorporate only non-specific factors) for social anxiety disorder (SAD). SAD symptoms were assessed after each treatment session in a sample of 45 college students. Independent assessors evaluated symptom severity at baseline, post-treatment and follow-up. A total of 10 (22.2%) participants experienced SGs during treatment. No differences were found in symptom improvement at post-treatment or follow-up between individuals with and without SGs. SGs appeared at similar rates across both treatments but were associated with greater improvements at post-treatment and follow-up in GPT compared to CBGT. Majority of SGs in CBGT occurred early in treatment before the provision of specific treatment techniques. These results suggest that non-specific treatment factors may be important in promoting SGs.

Different lens or different picture? Comparing methods of defining dramatic change in psychotherapy.

OBJECTIVES: Differing methodologies that identify dramatic change in psychotherapy have been thought to be capturing similar phenomena. We compared three methods-percentage improvement-50% (PI-50), rapid response (RR), and sudden gains (SG)-to identify similarities and differences between these approaches. METHODS: Using a large database (n = 11,764) from a western university counseling center, we examined client characteristics (including initial severity and number of sessions in a course of treatment) and treatment outcomes (including overall change and meeting clinically significant criteria) using the Outcome Questionnaire-45. RESULTS: Approximately 47% of clients (n = 5516) met criteria for one or more of the dramatic change definitions examined. Only 498 clients (3.7%) met criteria for all three methods, while 1349 (11.5%) met criteria for only one; RR identified the most clients (41.9%) and SG identified the fewest (4.9%). All definitions were associated with higher rates of clinically significant change at termination. Compared to those who recovered gradually, dramatic changers showed higher initial severity and more overall change. RR showed fewer sessions and PI-50 and SG showed more sessions than those who recovered gradually. CONCLUSIONS: Given these differences, consensus needs to be reached in the literature regarding the definition of dramatic change. We call for further theory development and research to help formulate a definition that can be simply applied and that more fully and parsimoniously captures the phenomenon of dramatic change.

Sudden gains in exposure-focused cognitive-behavioral group therapy for panic disorder.

In the context of psychological treatment, a sudden gain is a large and enduring improvement in symptom severity that occurs between two single therapy sessions. The influence of sudden gains on long-term outcomes and functional impairment in anxiety disorders is not well understood, and little is known with regard to panic disorder in particular. In addition, previous research on patients with anxiety disorders has produced inconsistent results regarding the relationship between sudden gains and cognitive change. We examined the incidence of sudden gains in a large sample (n = 116) of panic disorder patients undergoing exposure-focused cognitive-behavioral group therapy, and compared panic severity, functional impairment, and cognitive change in patients with and without sudden gains at posttreatment and 6-month follow-up. Participants who experienced sudden gains displayed lower levels of panic severity and functional impairment at posttreatment and 6-month follow-up than those who did not experience sudden gains. However, we observed no difference in cognitive changes between groups, either at posttreatment or at follow-up. Our results demonstrate that the beneficial effects of sudden gains on therapeutic outcomes not only extend to long-term and functional outcome measures but are also evident in less cognitive (i.e., exposure-focused) forms of psychological treatment. KEY PRACTITIONER MESSAGE: Sudden gains are common in panic disorder patients undergoing exposure-based cognitive-behavioral group therapy. Sudden gains during exposure-focused therapy are linked to greater improvement in panic disorder severity and functional impairment. The positive impact of sudden gains on panic disorder severity and functional impairment is maintained in the long term.

Sudden gains among women receiving treatment for alcohol use disorders.

Understanding the timing and types of change during treatment for mental health disorders is an important step toward elucidating possible mechanisms of behaviour change in response to therapeutic interventions, yet these issues have not been adequately addressed in the alcohol dependence treatment literature. The current study applied sudden gains (SGs) methodology, an approach originally developed in depression treatment studies, to a sample of women receiving treatment for alcohol use disorders. SGs are drastic improvements in symptoms that occur between two psychotherapy sessions and are hypothesised to be the result of what occurred in the first of those two sessions. SGs can happen at any time during the course of treatment, can happen more than once, and are individualised, as opposed to aggregated for a sample. For the current study, SGs were examined across three variables: percent drinking days (PDD), urge frequency (UF), and urge intensity (UI) in a sample of 102 women receiving either individual or couple cognitive-behavioural therapy for alcohol use disorders. Results indicated the presence of SGs; one-third of the sample experienced at least one SG in either alcohol use or urges to drink; the most common SGs were in frequency of urges to drink. SGs in urge frequency during treatment predicted better post-treatment drinking outcome.

Substantial symptom changes in naturalistic recovery from aversive events.

OBJECTIVE: Researchers have recommended examining trajectories of recovery from aversive events, including sudden gains and spikes. We examined rates, attributions for, and outcomes associated with substantial symptom improvements and brief exacerbations after aversive events. METHOD: Sixty-three women completed questionnaire measures of mood, depression, and posttraumatic stress disorder symptoms. They used a Life History Calendar (LHC) to draw the trajectory of symptom levels from the event to the present, and were interviewed regarding the course of their symptoms. Based on the LHC and interview, we coded whether each participant experienced substantial improvements and/or brief exacerbations and reasons for them. RESULTS: Participants frequently experienced substantial improvements and brief exacerbations, most of which they attributed to external events. Substantial improvements-but not substantial brief exacerbations-were associated with significantly lower symptom levels. CONCLUSION: Substantial improvements are similar to sudden gains in therapy samples. Substantial improvements in avoidance and mood have positive, bidirectional effects on each other.

Sudden gains in routine clinical care: application of a permutation test for trauma-focused cognitive behavioural therapy.

Background: Sudden gains, defined as large and stable improvements of psychopathological symptoms, are a ubiquitous phenomenon in psychotherapy. They have been shown to occur across several clinical contexts and to be associated with better short-term and long-term treatment outcome. However, the approach of sudden gains has been criticized for its tautological character: sudden gains are included in the computation of treatment outcomes, ultimately resulting in a circular conclusion. Furthermore, some authors criticize sudden gains as merely being random fluctuations.Objective: Use of efficient methods to evaluate whether the amount of sudden gains in a given sample lies above chance level.Method: We used permutation tests in a sample of 85 patients with posttraumatic stress disorder (PTSD) treated with trauma-focused cognitive behaviour therapy in routine clinical care. Scores of self-reported PTSD symptom severity were permuted 10.000 times within sessions and between participants to receive a random distribution.Results: Altogether, 18 participants showed a total of 24 sudden gains within the first 20 sessions. The permutation test yielded that the frequency of sudden gains was not beyond chance level. No significant predictors of sudden gains were identified and sudden gains in general were not predictive of treatment outcome. However, subjects with early sudden gains had a significantly lower symptom severity after treatment.Conclusions: Our data suggest that a significant proportion of sudden gains are due to chance. Further research is needed on the differential effects of early and late sudden gains.

Treatment-related sudden gains exhibit clinical significance when their manifestation is above chance level.We used permutation tests to examine their occurrence in trauma-focused cognitive behaviour therapy as applied in a naturalistic treatment setting.The occurrence of sudden gains in general was not significantly higher than chance, yet early sudden gains were associated with improved treatment outcome.

Sudden gains in face-to-face and internet-based cognitive therapy for social anxiety disorder.

Sudden gains are large and stable decreases in clinical symptoms between consecutive therapy sessions. This work examined the frequency and possible determinants of sudden gains in Cognitive Therapy for Social Anxiety Disorder, comparing face-to-face (CT) and internet-based (iCT) formats of treatment delivery. Data from 99 participants from a randomised controlled trial were analysed. The frequency of sudden gains was high: 64% and 51% of participants experienced a sudden gain in CT and iCT respectively. Having a sudden gain was associated with lower social anxiety symptoms at posttreatment and follow-up. There was evidence of reductions in negative social cognitions and self-focused attention immediately prior to the sudden gain, contrasting with no prior reductions in depression symptoms. Ratings of session videotapes in CT showed that clients' statements indicated greater generalised learning in sessions immediately prior to gains, compared to control sessions. This may suggest a role for generalised learning in facilitating these large symptom reductions. There were no significant differences in results between the CT and iCT treatment formats, suggesting that the therapy content appears to play a more important role in determining participants' large symptom improvements than the medium of treatment delivery.

Using machine learning to predict sudden gains in intensive treatment for PTSD.

Sudden gains have been found in PTSD treatment across samples and treatment modality. Sudden gains have consistently predicted better treatment response, illustrating clear clinical implications, though attempts to identify predictors of sudden gains have produced inconsistent findings. To date, sudden gains have not been examined in intensive PTSD treatment programs (ITPs). This study explored the occurrence of sudden gains in a 3-week and 2-week ITP (n = 465 and n = 235), evaluated the effect of sudden gains on post-treatment and follow-up PTSD severity while controlling for overall change, and used three machine learning algorithms to assess our ability to predict sudden gains. We found 31% and 19% of our respective samples experienced a sudden gain during the ITP. In both ITPs, sudden gain status predicted greater PTSD symptom improvement at post-treatment (t2 W=-8.57, t3 W=-14.86, p < .001) and at 3-month follow-up (t2 W=-3.82, t3 W=-5.32, p < .001). However, the effect for follow-up was no longer significant after controlling for total symptom reduction across the ITP (t2 W=-1.59, t3 W=-0.32, p > .05). Our ability to predict sudden gains was poor (AUC <.7) across all three machine learning algorithms. These findings demonstrate that sudden gains can be detected in intensive treatment for PTSD, though their implications for treatment outcomes may be limited. Moreover, despite the use of three machine-learning methods across two fairly large clinical samples, we were still unable to identify variables that accurately predict whether an individual will experience a sudden gain during treatment. Implications for clinical application of these findings and for future studies are discussed.

A Revised Theory of Sudden Gains in Psychological Treatments.

Sudden gains were first defined and quantified by Tang and DeRubeis (1999) and were found to predict treatment outcome in cognitive therapy for depression. Since that seminal paper, over 100 examinations of sudden gains have been published and sudden gains have been found to be ubiquitous in psychological treatments and to consistently predict better treatment outcomes across a multitude of disorders and contexts (see Shalom & Aderka, 2020 for a review). The research on sudden gains has seen considerable growth over the past 20 years. However, the theory behind sudden gains (which addresses processes leading to sudden gains, and processes resulting from sudden gains) has never been revised. Based on the empirical research which has accrued over the last 20 years, we present an empirically-based revision of the theory of sudden gains. The revised theory addresses both predictors of sudden gains and processes that may lead to sudden gains, as well as the consequences of sudden gains and the processes by which sudden gains can affect outcome. We also present a number of hypotheses that can be derived from the theory as well as the status of empirical evidence supporting these hypotheses. Research and clinical implications are discussed.