The phenomenon of sudden gains: A meta-analysis understanding how often sudden gains reverse and empirical study exploring how therapists can support sudden gain maintenance.

When individuals undergoing therapy make a large stable improvement in symptoms between two time-points, called a sudden gain, existing research would suggest that they are more likely to have better therapeutic outcomes overall. A sudden gain has been related to improved treatment outcome in individuals undergoing a range of therapies from cognitive behavioural therapy (CBT) to psychodynamic therapy and, for a diverse range of disorders such as anxiety, depression, and eating disorders. Research has since been largely dedicated to understanding the predictors of sudden gains which has resulted in inconsistent findings, leaving a diverse range of possible predictors and a lack of clarity in the research. Not all sudden gains are maintained and lead to superior outcomes, and some individuals experience a sudden gain reversal. This research project, made up of a meta-analysis and empirical paper, aimed to understand more about sudden gain reversals and the therapist guided processes supporting the possible maintenance of a sudden gain. The meta-analysis aimed to understand the prevalence of sudden gain reversals in individuals undergoing therapy for depression. Study level characteristics predicted to impact the rate of sudden gain reversals included which sudden gain criterion was used, the outcome measure for depression employed and, the type of therapy that was delivered. A systematic search of online databases yielded 22 papers that reported the sudden gain reversal rates for individuals in therapy for depression. The review found that 29% of sudden gains reversed over course of therapy. Higher rates of reversals were observed in therapies such as cognitive therapy and other non-cognitive or behavioural based therapies compared to lower rates in CBT and behavioural activation. Significantly fewer reversals were evidenced when individuals completed the Patient Health Questionnaire-9 compared to other measures for depression. The main paper outlines the limitations and research recommendations in further detail. As clear in the meta-analysis, sudden gain reversals suggest that not all sudden gains are maintained and lead to superior outcomes. The upward spiral theory hypothesises that when people make a sudden gain in therapy, this leads to increased therapeutic alliance and further cognitive change resulting in superior outcomes. A key paper suggested four components needed to support individuals from a sudden gain to an upward spiral including identifying the gain, exploring reasons for the gain, finding meaning in the gain and leveraging the gain. The empirical paper used a task analysis methodology to explore if the four components support individuals to maintain a sudden gain. The analysis corroborated and adjusted the theorised model. The final model suggested that to support an individual who has had a sudden gain to an upward spiral the therapist should assist them to identify the gain, explore reasons for the gain, stay with the positive discussion around the gain, use the gain and reference the ending of therapy. Large scale validation of the model is needed. Limitations and implications for practice are discussed in the empirical paper.