When clients in therapy show sudden, dramatic improvements

There's growing evidence that people who undergo psychological therapy often demonstrate sudden, dramatic improvements, almost as though they've had a revelatory change of outlook and thinking style. What's more, these sudden changes appear to be clinically meaningful. People who exhibit sudden improvements from one session to the next are more likely than other clients to show greater and more sustained improvement after they've stopped participating in therapy.

Now Elise Clerkin and colleagues at the University of Virginia have investigated the significance of sudden gains among 30 clients undertaking 12 weeks of group Cognitive Behavioural Therapy (CBT) for panic disorder - a context in which the sudden-improvement phenomenon has yet to be studied.

Clerkin's team found that 43 per cent of clients exhibited at least one dramatic burst of improvement during the course of therapy. Approximately half of these clients showed this improvement between the first and second sessions, while the other half showed their gains later on.

The timing of the sudden improvement proved to be significant. Only those clients who showed dramatic gains after the second session or later tended to show better symptom outcomes at the end of the course of therapy relative to non-dramatic improvers. This makes sense given that the first session was really just an introduction and didn't include any of the active ingredients of CBT.

Moreover, the later dramatic improvers showed a greater reduction in their fear of anxiety-related symptoms (e.g. a racing heart-beat) at the end of the course of therapy (and at six months' follow-up) than did the very early dramatic improvers. This suggests that when a dramatic improvement occurred after the second session or later it probably had to do with the clients changing how they interpreted their anxiety symptoms - one of the key goals of CBT. By contrast, very early dramatic improvement may have reflected a meaningless fluctuation of symptoms.

The researchers said more work is needed to find out what psychological processes underlie the effects of a dramatic improvement during therapy. "We suspect these effects occur because of changes in self-efficacy that follow a large, dramatic improvement, which likely engenders hope for further recovery, and enhances commitment to the therapy," they surmised. "In fact, the sudden gain itself may confer a critical belief change regarding the patient's ability to overcome symptoms of panic."
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E CLERKIN, B TEACHMAN, S SMITHJANIK (2008). Sudden gains in group cognitive-behavioral therapy for panic disorder. Behaviour Research and Therapy DOI: 10.1016/j.brat.2008.08.002

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