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

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.

Processes related to sudden gains: critical therapeutic events and attributions Note: • Every change should get an individual magnitude score. Even when they're in the same category. For example, if you notice two changes with regard to changes in beliefs write them both down and rate them individually (as if this would be the only one). • Sometimes it is difficult to determine whether two activities are separate enough to deserve their own magnitude score. Rules of thumb: o Situations deserve their own magnitude score if the topic is different, a significant amount of time is spent on each example, and the discussion about each example ends with a specific conclusion. o Situations do not deserve their own magnitude score if: several examples are 'listed' without further exploration in the session (e.g. client says: 'I can try to call my friend, go for a walk, fix my car, look up information about traveling with groups, work on my family tree', but no further examination is done). o Sometimes it can be a combination of the two situations mentioned above. But only if this is explicitly acknowledged in the session as such.
(e.g. patient and therapist generate a list of things the patient can try. They explicitly make a distinction between things she can do by herself, and things she can do with others.

The patient became aware of the relationship between cognition and mood
High scores if the patient explicitly acknowledges the relation between cognition and mood, and/or gives specific examples to illustrate this. Note: in sessions were awareness about the relationship between interpersonal functioning and mood is raised because the therapist provides the interpersonal rational, the client's (spontaneous, of therapist initiated) reaction determines whether a magnitude score is given! If the client responds to the rational (e.g. by recognizing/acknowledging this pattern, or giving a specific example), or client and therapist use this information to actively work on this together, a magnitude can be given to this item. If the therapist only tells the patient about it, without further exploring this and/or the patient does not explicitly respond to this (but instead e.g. only nods), this can be rated as no change.

No Yes
Specify: In today's session? Explain: Prior to the session? Was this given as a reason for symptom improvement? Processes related to sudden gains: critical therapeutic events and attributions

INTERPERSONAL CHANGE
Note: carefully read the wording of the items to see the subtle difference between item 1 2 3 vs. 4 5 6. Main difference is that for 1 2 and 3, the awareness of the role of interpersonal functioning has to be there in order to receive a magnitude score (aware). Items 4, 5, 6 can be rated without an explicit link to interpersonal change (decided, made plans, changed). For example question 3: the wording of the item allows a magnitude score if a patient decides to increase interpersonal functioning, even though this is mainly from an increase activities point of view instead of a conscious interpersonal link (because literally seen, the patient has decided to increase this). It has to be noted however, that this will probably be a low score.

The patient became aware of the relation between interpersonal functioning and mood
Note: in sessions were awareness about the relationship between interpersonal functioning and mood is raised because the therapist provides the interpersonal rational, the client's (spontaneous, of therapist initiated) reaction determines whether a magnitude score is given! If the client responds to the rational (e.g. by recognizing/acknowledging this pattern, or giving a specific example), or client and therapist use this information to actively work on this together, a magnitude can be given to this item. If the therapist only tells the patient about it, without further exploring this and/or the patient does not explicitly respond to this (but instead e.g. only nods), this can be rated as no change.