The ups and downs of psychotherapy: Sudden gains and sudden losses identified with session reports

Abstract

Psychotherapy does not always follow a linear path. The present study explores the frequency of sudden gains and losses during the course of outpatient psychotherapy. The sample includes 1500 patients treated at three different outpatient centers. The patients were 57.4% female, and suffered primarily from anxiety and depressive disorders. Progress was measured by session reports. Significant sudden shifts in both directions were prevalent for 28.9% of the patients. Patients with early sudden gains showed the highest effect sizes and patients with sudden losses showed the smallest at the end of treatment. The therapeutic relationship was significantly better after the sudden gain sessions. Results suggest further investigation of the occurrence of sudden gains in relation to early response as well as further exploration of sudden losses during the course of treatment with respect to differential patterns of change and outcome.

Psychotherapie verläuft nicht immer entlang eines linearen Pfades. Die vorliegende Studie untersucht die Häufigkeit von sudden gains und sudden losses im Verlauf ambulanter Psychotherapie. Die Stichprobe enthält 1500 Patienten, die an drei unterschiedlichen ambulanten Zentren behandelt wurden. Die Patienten waren zu 57.4% weiblich und litten hauptsächlich an Angststörungen und Depressionen. Der Fortschritt wurde mittels Sitzungsbögen erhoben. Plötzliche, signifikante Veränderungssprünge wurden bei 28.9% der Patienten gefunden. Patienten mit frühen positiven Veränderungssprüngen zeigten die besten Effektstärken zum Ende der Therapie und Patienten mit negativen Veränderungssprüngen zeigten die niedrigsten. Die therapeutische Beziehung war signifikant besser nach Sitzungen mit einem positiven Veränderungssprung. Die Ergebnisse legen weitere Untersuchungen bzgl. des Auftretens von sudden gains in Beziehung zum Konzept früher positiver Veränderungen, sowie eine Exploration von sudden losses im Therapieverlauf bezogen auf differentielle Veränderungsmuster und Therapieergebnis nahe.

La psicoterapia non sempre segue un percorso lineare. Il presente studio esplora la frequenza dei miglioramenti e dei peggioramenti improvvisi nel corso della psicoterapia ambulatoriale. Il campione comprende 1500 pazienti trattati in tre centri ambulatoriali diversi. I pazienti erano per il 57,4% di sesso femminile e soffrivano soprattutto di disturbi d'ansia e depressione. Il progresso è stato misurato mediante i report delle sedute. Significativi cambiamenti improvvisi in entrambe le direzioni hanno predominato per il 28,9% dei pazienti. I pazienti con miglioramenti improvvisi precoci hanno mostrato i maggiori effect-sizes e i pazienti con peggioramenti improvvisi i minori effect-sizes alla fine del trattamento. La relazione terapeutica è risultata significativamente migliore dopo le sedute di miglioramento improvviso. I risultati suggeriscono ulteriori indagini rispetto alla manifestazione di miglioramenti improvvisi in relazione alla risposta precoce così come l'esplorazione dei peggioramenti improvvisi durante il corso del trattamento riguardo ai pattern differenziali di cambiamento e di esito.

A psicoterapia nem sempre segue um caminho linear. O presente estudo investiga a frequência dos ganhos e perdas repentinas durante o curso da psicoterapia em pacientes de ambulatório. A amostra incluiu 1500 pacientes tratados em três diferentes centros de ambulatório. Os pacientes eram 57.4% do sexo feminino e sofriam principalmente de perturbações de ansiedade e depressão. O progresso foi medido pelos relatos de sessão. As mudanças repentinas significativas em ambas as direcções foram prevalentes em 28.9% dos pacientes. Os pacientes com avanços precoces repentinos demonstraram um maior efeito significativo e pacientes com perdas repentinas mostraram um menor efeito no final do tratamento. A relação terapêutica foi significativamente melhor depois dos ganhos repentinos nas sessões. Os resultados sugerem mais investigação na ocorrência de ganhos repentinos no que respeita a respostas precoces, bem como maior pesquisa de perdas repentinas durante o decurso do tratamento relativamente a padrões diferenciais de mudança e resultado.

La psicoterapia no siempre recorre un amino lineal. El presente estudio analiza la secuencia de avances y retrocesos en procesos terapéuticos conducidos en régimen de consulta externa. La muestra consta de 1500 pacientes atendidos en tres centros de atención. Los pacientes consultaban fundamentalmente por depresión y trastornos de ansiedad. El avance del proceso terapéutico se midió a través de reportes sobre las sesiones. Aparecieron movimientos significativos en ambas direcciones en 28.9% de los pacientes. Los pacientes que presentaron avances imprevistos en las etapas tempranas del tratamiento fueron los que luego tuvieron mayores tamaños del efecto en los resultados finales del tratamiento, mientras que aquellos que mostraron retrocesos repentinos fueron los que, al final del proceso, habían tenido menores resultados. Luego de los episodios abruptos de mejoría, la relación terapéutica mejoraba significativamente. Este estudio sugiere que es necesario profundizar la investigación sobre los avances repentinos en las primeras etapas del tratamiento, así como sobre los retrocesos inesperados a lo largo del proceso, en la búsqueda de determinar patrones diferenciales de proceso y resultados.

Keywords:

• sudden gains
• sudden losses
• patient-focused research
• process-outcome research

Acknowledgements

This work was partially supported by grants from the Swiss National Science Foundation (SNF), Nr. PP001-102651, the research initiative Rhineland-Palatinate and the Humboldt Foundation (TransCoop Program) (Wolfgang Lutz). We thank Prof. Dr. Klaus Grawe as well as Prof. Dr. Dietmar Schulte for providing the data and videotapes for those two projects as well as the clinical teams from the outpatient centers at the University of Bochum as well as from the University of Berne and the University of Trier. We also thank Susan Noel for her helpful comments on earlier drafts of this manuscript.

Notes

1. This subscale consists of six items: 1. “I have the feeling that I better understand myself and my problems”; 2. “Today we got closer to the core of my problems”; 3. “Today I became aware why I react towards some people in a certain way and not in a different way”; 4.“I am now better able to cope with problematic situations, were I was not able to cope with before treatment”; 5.“Now I am more confident to solve my problems by myself”; 6.“Now I know better what I want.” We used the factor structure demonstrated by Flückiger, Regli, Zwahlen, Hostettler and Caspar (2010).

2. For the 22 patients from the University of Trier only 46 of those 64 items were available. For the other 1478 patients the correlation between the means of these 46 items and the means of the full 64 items were r = .99.

3. Additional data about the frequencies of sudden gains/losses using different criteria can be obtained on request from the authors.

4. Confidence intervals were computed using the following equation:

with P representing the probability of the occurrence of a certain result in the respective group and Q standing for the complementary probability (1−P); n being the sample size of the respective group (e.g., Freund, 1967).

5. Average pre-/post effect sizes were calculated using the formula:

with M _pre representing the mean of all scores at the beginning of therapy, M _post the mean of the scores after the treatment and SD _pre the standard deviation of M _pre .