Sudden gains
Why change in therapy proceeds more often in jumps than we think.
In practice and research it has been reported for more than three decades: patients do not always improve gradually. Sometimes they make a sudden leap forward — between two sessions, without our being able to point precisely to what caused it.
The term is sudden gains: sudden, substantial and lasting symptom improvements between two consecutive treatment moments. Tang and DeRubeis wrote the canonical article in 1999: they defined the leap as large (in absolute terms), dramatic (in relative terms) and stable (not disappearing again). In depression they found it in a considerable proportion of patients, and those who had made such a leap did better in the long run.
Since then the phenomenon has seemed time and again confirmed: in depression, in anxiety disorders, in PTSD, in eating disorders, in OCD. It seems not to be an artefact of one measurement moment or one type of treatment. People improve, to our minds, sometimes truly in jumps.
What makes it hard to place
In our usual images of therapy, change tends to run gradually. A patient learns skills, learns them better, uses them better, and the complaints gradually diminish. Cognitive schemas shift slowly. Exposure effects cumulate. It is a classical dose-response model: more therapy, more effect.
Much improvement, however, does not answer to that image. Sometimes it takes place in jumps, and often even before the "great" intervention of the protocol has occurred. Not seldom without patient or clinician being able to point precisely to which specific moment marked the breakthrough.
What it shows
Various explanations are advanced. Some researchers point to cognitive restructuring that tips at a specific moment. Others to the building of hope and trust early in treatment. Still others to processes of self-organisation — a system that, after a period of increasing variability, restabilises in a different pattern.
Schiepek and colleagues study the phenomenon from that latter perspective. With daily measurements, they often see preceding a sudden gain a period of heightened variability in mood, complaints and behaviour — a kind of unrest in the system before it reorganises itself.
"Discontinuous progression seems to be the rule rather than the exception." — Schiepek et al. (loosely translated)
For practice
What to do with this knowledge? We arrive, cautiously formulated, at several considerations.
First: perhaps we may normalise it more. Patients themselves often expect linear progress too. When they are suddenly much better, they wonder whether it is real, and they fear relapse. When they are not improving, they see this as proof that their treatment is not working. Both reactions seem not quite justified: jumpy change is, to our impression, a frequent pattern, and is sometimes already in the making while invisible from the outside.
Second: we may, to our minds, be critical of the thought that "more protocol execution" is always the right intervention in a slow course. Sometimes a patient needs first the right conditions in which her system can reorganise itself, rather than more technique. What those conditions are differs per person.
Third: we may perhaps adjust our measurements. One who takes a weekly questionnaire sees the leap, but misses the unrest preceding it. One who measures daily (or a few times a day) often sees more.
Modesty fits here too
The literature on sudden gains is extensive, but many underlying mechanisms remain unclear. We know that the phenomenon occurs. We know that it relates to a better long-term outcome. We have some sight on which preceding signals make it likelier that something is going to shift. What we do not know, however, is how we could reliably evoke them.
And perhaps that is precisely where the idea of self-organisation enjoins caution. What arises in another system does not always lend itself to planning. It sometimes comes. And it often comes at a moment that an outsider does not at once understand — only afterwards do we seem to see the coherence.