Maintaining Gains in CBT

One of my favorite things about cognitive behavioral therapy (CBT) is how quickly it makes a difference in the lives of clients who receive it.

In my clinical practice, I often see that something “clicks” in my clients after 4-8 sessions of CBT. That is, after 4-8 sessions, many clients who diligently practice their CBT tools in between sessions report that they feel better, that their problems seem less overwhelming, and that they have hope that their can achieve fulfillment and life satisfaction. The research literature has confirmed this phenomenon, with scholars referring to these improvements as “sudden gains.”

The notion of “sudden gains” is not new. Over a decade ago, Tang and DeRubeis (1999) found that over 50% of clients who ultimately respond to CBT experience a sudden gain, and impressively, that sudden gains were maintained across the rest of treatment and persisted 18 months following treatment in most cases.

What can therapist and clients do to put themselves in the best position to have a sudden gain?

Therapists can make sure that clients thoroughly understand the theory that underlies CBT and can articulate the manner in which it applies to their lives.

Therapists and clients can practice the CBT tools in session to ensure that clients understand exactly how to use them and to increase clients’ confidence that they’ll be able to apply them in their lives outside of session.

Clients can fully commit to completing the between-session work in order to gain practice with the CBT tools.

If it initially appears that the CBT tools are not helpful, then therapist and clients can work together to creatively modify them on the basis of clients’ preferences, strengths, and challenges while still retaining their “spirit.”

I’ve also seen some instances when clients experience a sudden gain after using one or two specific CBT tools, then choose to focus on something else in subsequent sessions, and then forget to apply the tools the next time the encounter a stressor in their lives. This is not unexpected — in many instances, unhelpful cognitive and behavioral patterns that characterize clients when they first present for treatment are entrenched. Even if it seems that they are modified after only a few sessions of CBT, it is important to realize that CBT tools are life skills that must be incorporated into one’s typical way of viewing the world and behaving, not just be practiced in a few sessions and then forgotten about.

Thus, to ensure that clients’ sudden gains are maintained over time, therapists and clients can do the following:

Clients can continue to practice CBT tools in between sessions, even if the focus of therapy has moved in another direction, in order to ensure that the tools are activated just as easily as unhelpful patterns of thinking and behavior.

Therapists and clients can focus on relapse prevention in session, such that they anticipate future stressors that might trigger unhelpful thinking and behavior and “cope ahead” to articulate the precise manner in which CBT tools will be applied to handle them.

Clients can create easy-access reminders of the CBT work done in session (e.g., a description of a CBT tool on an index card) and consult the reminders immediately in times of vulnerability.

I often use the metaphor of a “groove in the brain” with my clients. If a client who struggles with depression has been thinking and behaving in an unhelpful manner for several years, it makes sense that her “depression groove” would be quite deep. CBT helps clients to carve out a new “groove in the brain.” However, time and practice are needed to ensure that the new groove is as deep as the original groove, and often, this practice occurs even after the course of CBT has ended.

My advice to people who have tried CBT but have found it unhelpful? Keep an open mind, and fully commit to practicing CBT tools for several weeks before drawing the conclusion that they are unhelpful. It may just be that the new groove has been dug out fully. With time and patience, you will see that you will acquire new cognitive and behavioral patterns, and it is very possible that all of the work you put in will suddenly come together in the form of a sudden gain.

Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitive behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 67, 894-904. doi: 10.1037/0022-006X.73.1.168

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