The role of general change mechanisms in sudden gains in the treatment of anorexia nervosa

Previous research has shown a robust association between sudden gains (SGs) and treatment outcome in psychotherapy for various mental disorders including anorexia nervosa (AN). However, little is known about factors contributing to SGs. This study investigated the role of general change mechanisms in body-weight related SGs in AN. Data were drawn from a randomized-controlled trial on cognitive-behavioral therapy (CBT) and focal psychodynamic therapy (FPT) for adult outpatients with AN. Session-level data on the general change mechanisms 'clarification' (insight), 'mastery' (coping), and 'therapeutic relationship' were analyzed. Pre-gain sessions were compared with control (pre-pre-gain) sessions in 99 patients with a SG in body weight. Additionally, propensity score matching was used to compare data from pre-gain sessions from 44 patients with SG and data from the corresponding session from 44 patients without SG. In the pre-gain session, patients experienced higher levels of clarification and mastery but not therapeutic relationship. Compared to patients without a SG, patients with a SG likewise experienced more clarification and mastery but not a better therapeutic relationship in the pre-gain/corresponding session. CBT and FPT did not differ regarding these effects. The findings suggest that general change mechanisms contribute to SGs in CBT and FPT for AN.

Using machine-learning to predict sudden gains in treatment for major depressive disorder

OBJECTIVE

Sudden gains during psychotherapy have been found to consistently predict treatment outcome but evidence on predictors of sudden gains has been equivocal. To address this gap, the present study utilized three machine learning algorithms to predict sudden gains during treatment for major depressive disorder.

METHOD

We examined predictors of sudden gains in two large samples of individuals receiving treatment in a partial hospital setting (n = 726 and n = 788; total N = 1514). Predictors included age, gender, marital status, education, employment status, previous hospitalization, comorbid diagnoses, and pretreatment measures of depressive and generalized anxiety symptoms. We used three machine learning models: a Random Forest model, a Random Forest model with an adaptive boosting meta-algorithm, and a Support Vector Machine model.

RESULTS

In both samples, sudden gains were identified and found to significantly predict outcome. However, none of the machine learning algorithms was able to identify robust predictors of sudden gains. Thus, even though some models achieved fair prediction of sudden gains in the training subset, prediction in the test subset was poor.

CONCLUSIONS

Despite the use of a large sample and three machine-learning models, we were unable to identify robust demographic and pretreatment clinical predictors of sudden gains. Implications for clinical decision making and future studies are discussed.

Are some therapists better at facilitating and consolidating sudden gains than others?

BACKGROUND

Changes during psychotherapy often include sudden symptom improvements, called sudden gains (SGs), which have been identified as being superior to gradual symptom change with regard to treatment success. This study investigates the role of therapists in initiating and/or consolidating SGs.

METHODS

The analyses are based on a sample of patients (N = 1937) who were seen by 155 therapists and received individual psychotherapy at a university outpatient clinic. First, the therapist effect (TE) on SG was investigated using multilevel modeling (MLM). Second, MLM was used to explore the relative importance of patient and therapist variability in SGs as they relate to outcome.

RESULTS

The TE on SGs accounted for 1.8% of variance, meaning that therapists are accountable for inter-individual differences in their patients' likelihood to experience SGs. Furthermore, results revealed a significant effect of SGs on outcome for both levels, while therapist differences regarding the consolidation of SGs were not significant.

CONCLUSIONS

The analyses indicated that some therapists are better in facilitating and initiating SGs. The process of triggering SGs seems to be a therapist skill or competence, which opens up an additional pathway to positive outcomes that could be used to improve clinical training.

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.

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.

Validity and reliability of the Eating Problem Checklist

The aim of this study was to validate the latest version of the Eating Problem Checklist (EPCL), a tool designed to assess eating-disorder behaviours and psychopathology in patients with eating disorders, session-by-session. The EPCL was completed at baseline by participants with eating disorders (n = 161) and a healthy control group (n = 379) and then administered session-by-session in a subgroup of 75 participants with eating disorders. The EPCL demonstrated good internal consistency, test-retest reliability, and concurrent and criterion validity, and principal axis analysis of the session-by-session data identified two factors ('eating concerns' and 'body image concerns') that accounted for 51.3% of the variance. Furthermore, session-by-session analysis indicated that the EPCL is able to identify specific weekly improvements and/or deterioration in eating-disorder psychopathology. These findings suggest that the EPCL is a valid and reliable self-report questionnaire that provides relevant clinical information regarding weekly changes in eating-disorder behaviours and psychopathology in patients with eating disorders.

Predictors of outcome in cognitive behavioural therapy for eating disorders: An exploratory study

OBJECTIVE

Early decrease in symptoms is a consistent predictor of good treatment outcome across all eating disorders. The current study explored the predictive value of novel early change variables in a transdiagnostic, non-underweight sample receiving 10-session cognitive behavioural therapy.

METHOD

Participants who reported bingeing and/or purging in the week preceding baseline assessment (N = 62) were included in analyses. Early change variables were calculated for novel (body image flexibility, body image avoidance, body checking, and fear of compassion) and established predictors (behavioural symptoms and therapeutic alliance). Outcomes were global eating disorder psychopathology and clinical impairment at posttreatment and three-month follow-up. Intent-to-treat analyses were conducted using linear regression, adjusting for baseline values of the relevant outcome and early change in behavioural symptoms.

RESULTS

Early improvement in body image flexibility was the most consistent predictor of good outcome. Early change in body image avoidance and the fear of expressing and receiving compassion to/from others were significant predictors in some analyses.

DISCUSSION

Novel early change variables were significant predictors of eating disorder outcomes in this exploratory study. Model testing is required to understand the exact mechanisms by which these variables impact on outcomes, and whether there is potential benefit of modifying existing protocols.

ANZCTR TRIAL NUMBER

ACTRN12615001098527.

Sudden gains in the outpatient treatment of anorexia nervosa: A process-outcome study

OBJECTIVE

Sudden gains (SGs), broadly defined as sudden symptom reductions occurring between two consecutive treatment sessions, have been associated with improved treatment outcomes in anxiety and depression. The present study is the first to formally define SGs in anorexia nervosa and explore the characteristics, demographic and baseline clinical predictors, and clinical impact of SGs in anorexia nervosa.

METHOD

This is a secondary analysis of data from 89 outpatients with broadly defined anorexia nervosa who received one of two psychotherapeutic interventions as part of the MOSAIC trial (Schmidt et al., 2015). SGs were defined using session-by-session body mass index (BMI) measures. This study investigated whether SGs were associated with changes in BMI, eating disorder symptomology, general psychopathology, and psychosocial impairment between baseline and 6, 12, and 24 months follow-up.

RESULTS

SGs, experienced by 61.8% of patients, mostly occurred during the early and middle phases of treatment. A larger proportion of SGs predicted larger increases in BMI between baseline and 6, 12, and 24 months follow-up. Amongst those experiencing at least one SG, fewer days between baseline and a patient's first SG predicted a larger increase in BMI between baseline and both 6 and 12 months follow-up. The proportion and timing of SGs did not predict changes in other outcome measures.

DISCUSSION

SGs in BMI during the outpatient treatment of anorexia nervosa are clinically useful predictors of longer-term weight outcomes.

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.

Extreme deviations from expected recovery curves and their associations with therapeutic alliance, social support, motivation, and life events in psychosomatic in-patient therapy

OBJECTIVES

Within the clinical support tools (CST) of the OQ-Analyst, the "Assessment for Signal Cases" (ASC) evaluates the therapeutic alliance, social support, motivation, and life events. We investigated whether the ASC covers domains of importance in treatment weeks with extreme deviations from expected recovery curves (ERCs).

METHODS

Psychosomatic in-patients were monitored weekly with the ASC and the "Outcome Questionnaire" (OQ-45). The ERCs of the OQ-45 empirical algorithm were used to define treatment weeks with extreme positive deviations (EPD), extreme negative deviations (END), or without extreme deviations (NO). Associations between the ASC scales and EPD as well as END were analyzed by multilevel models.

RESULTS

While each ASC scale was positively associated with EPD, only the social support and life events scales were negatively related to END.

CONCLUSIONS

CSTs prioritizing social support and life events might be more effective in preventing treatment failure.