Sudden gains observed in both internet-based and face-to-face therapy sessions for social anxiety

A recent study in the United Kingdom examined the frequency of sudden large reductions in social anxiety symptoms in face-to-face and internet-based therapy sessions. The results revealed that 64% of patients in face-to-face therapy and 51% of patients in internet-based therapy experienced substantial reductions in their symptoms. Negative social cognitions and self-focused attention tended to decrease immediately before the improvement. The study was published in Behaviour Research and Therapy.

“Sudden gains” in psychotherapy are significant and rapid improvements in a client’s symptoms or overall well-being that occur between two therapy sessions. These reduction in symptoms happen over a short period of time, such as a week or two. Researchers and therapists have noted the occurrence of sudden gains across various therapeutic approaches and client populations. Due to this, the sudden gains phenomenon is considered an essential aspect of the therapeutic process.

Some theories suggest that sudden gains may result from cognitive shifts, increased insight, or the consolidation of learning during therapy sessions. Therapists often track and explore sudden gains to better understand the factors contributing to a client’s progress. Studies on individuals suffering from social anxiety disorder show that typically around 20% of patients show a sudden gain, while the overall percentage for all disorders is 34%. In spite of the importance of sudden gains, scientists are still not certain about the exact factors and their interactions that produce a sudden gain.

Study author Graham R. Thew and his colleagues wanted to examine the occurrence and possible determinants of sudden gains in individual cognitive therapy for social anxiety disorder. In particular, they wanted to compare face-to-face and internet-based therapy in how often they result in sudden gains. Although sudden gains have been reported in internet-based therapy, it is unclear whether they occur as frequently as in face-to-face therapy.

The study involved 99 individuals, aged 18 to 65, diagnosed with social anxiety disorder, who were part of a larger study comparing face-to-face and internet-based therapy. Of these, 50 attended face-to-face therapy, and 49 participated in internet-based therapy. The treatments spanned 14 weeks, with follow-ups at three and twelve months post-treatment.

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The in-person sessions were conducted weekly, lasting 90 minutes each. In contrast, the internet-based sessions included a 20-minute phone call and additional communication via messaging and SMS throughout the week between the patient and therapist. The internet-based therapy also incorporated a webcam experiment during the second week.

Before each face-to-face session or once a week for internet-based therapy patients, participants completed assessments of social anxiety symptoms (the Liebowitz Social Anxiety Scale – Self-Report version and the Anxiety Disorders Interview Schedule), negative social cognitions (the Social Cognition Questionnaire, SCQ), self-focused attention (2 items from the Social Phobia Weekly Summary), and depressive symptoms (the Patient Health Questionnaire).

The researchers defined a sudden gain as a reduction in anxiety symptom scale scores significantly exceeding the regular variations in anxiety symptoms. They also reviewed sessions preceding a sudden gain, believing that the events within these sessions might be pivotal for understanding the gain. These sessions were analyzed to identify the occurrence of generalized learning, defined as “new learning arising from any therapy activity that applies across a range of different social contexts and involves drawing a more general conclusion about the self, others, or social situations.”

Of the 1,089 intervals between sessions analyzed, 77 (7%) were classified as sudden gains. 32 face-to-face therapy patients (64%) and 25 internet-based therapy patients (51%) experienced a sudden gain. However, statistical tests indicated that the difference in occurrence rates between the two therapy modes was not significant enough to infer a general trend. The average magnitude of the sudden gains was similar in both therapy types.

Further analyses revealed that participants who experienced sudden gains had lower social anxiety symptoms at the end of the treatment and at both follow-ups compared to those who did not experience them. This indicates that effects of sudden gains persisted – they were not temporary.

At the same time when a sudden gain happened i.e., when social anxiety symptoms decreased, self-focused attention, negative social cognitions, and depressive symptoms decreased as well. Self-focused attention and negative social cognitions (but not depressive symptoms) also showed a decrease in the session immediately prior to the one where a sudden gain was detected. The researchers detected pronounced general learning in the session immediately before the sudden gain.

“This study has shown that sudden gains can occur in online therapies, and that these gains are similar in frequency, magnitude, and clinical significance to those seen in face-to-face cognitive therapy,” the study authors concluded. “Having a sudden gain predicted better overall therapy outcomes. The results provided evidence of reductions in negative social cognitions and self-focused attention occurring prior to sudden gains, but not changes in depressed mood. Clients’ statements in cognitive therapy sessions indicated greater generalised learning in pregain compared to control sessions, suggesting a possible association between generalised learning and the occurrence of sudden gains.”

While the study illuminates the nature of sudden gains in psychotherapy, it also has limitations. The study authors noted that their method for detecting sudden gains could lead to false positives. Moreover, since assessments were conducted before each week’s therapy session, it was not possible to differentiate between gains occurring during a session and those happening during the intervening week.

The study, “Sudden gains in face-to-face and internet-based cognitive therapy for social anxiety disorder”, was authored by Graham R. Thew, Anke Ehlers, and David M. Clark.