Is change always linear?
The short answer is "No"! In this article, I’ll expand upon that answer, sharing what both myself and the research has found occurring during the process of change through therapy.
When you take antibiotics for an infection, you gradually start to get over the infection and feel better. You might seem to improve day by day, always moving towards health with no setbacks or reoccurrence of your symptoms (providing you take the full course of tablets obviously). Progress is gradual and linear in this case.
I think because we experience progress in this way for some physical conditions, we expect the same kind of process with our mental health. We experience anxiety or depression, we get some tablets or go to see a therapist of some kind, and assume that things will just get better now.
But more often than not, this is not how things pan out. We make an initial improvement and then the anxiety or depression creeps in again, before receding. This cycle continues, although with bigger gaps in between, until you are feeling more in control of how you feel.
So what happens when a client has that first dip back into their problem? Because they’ve had a glimpse of how things could be better, when their symptoms come back, it feels like they are worse than they were before. It generally isn’t, it just feels it because they have a more recent comparison between how it feels when they are anxious or depressed and feeling more ‘normal’ (whatever that is).
They often think “Oh no, it’s back”, then “The therapy isn’t working” or “I’m not doing it right”, followed by “I’m back to square one” and “I’m always going to feel this way”. This line of thinking is only natural.
We base everything on our past experiences. When we’ve had an issue, for example, anxiety or depression, when symptoms come up that we associate with that issue, we instantly assume that it must be that again. We lose perspective on what is happening. So feeling butterflies about getting on the plane to fly somewhere exotic, we might interpret as anxiety. Or if we’re feeling a bit low, we might assume that the depression is back. Whereas, someone who has never had anxiety and depression would see the situation for what it is - excitement because they are going on holiday or a low mood because we all have down days.
Up until now, I’ve been talking about my own experiences with clients. So let’s have a look at the research. Hayes, Laurenceau, Feldman, Strauss & Cardaciotto (2007) state that “although change can happen in a gradual and linear way, there is increasing evidence from across disciplines that it can also occur in discontinuous and nonlinear ways.” When we’ve been carrying out thoughts and behaviours in a specific way for some time, change often is not gradual and linear. Instead, we get a variability of our thoughts and behaviours, a mix of our old ways of doing things combined with the new ones, until things start to level out. (Kelso, 1997; Thelen & Smith) Some theoretical models propose that there are distinct points throughout therapy where change accelerates, dips, and levels off. (Collins, 2006)
The process of change in Cognitive Behavioural Therapy (CBT) has been researched for depression. The findings showed an ‘early rapid response’ which is characterised by a substantial decrease in depression symptoms over the first few sessions before things level out. (Ilardi & Craighead, 1994) Tang & DeRubeis (1999) also noted another kind of improvement which occurs in the first few sessions of therapy, which they termed ‘sudden gains’. This is a single event where significant improvement occurs in between two therapy sessions and doesn’t reverse. In addition to these patterns of change, Hayes et al (2007) also identified a ‘depression spike’ which is a sudden increase in depression symptoms followed by a decrease. I have witnessed early rapid response, sudden gains and depression spikes with most of my depression clients over the years. All of the above research has shown that these nonlinear patterns of change predicted more improvement in depression at the end of therapy. This is reassuring, both to therapists and clients alike.
So with all this knowledge, let’s look at those thoughts that clients typically have in a more rational way:
“Oh no, it’s back” - yes it is. Momentarily. It doesn’t mean it’s back for good though. You have the support of a therapist now and you’re learning ways to help you manage your thoughts, feelings and behaviours better.
“The therapy isn’t working” - this is not the case. Change isn’t always linear and it’s expected that there might be peaks and troughs in the early stages of therapy in particular.
“I’m not doing it right” - the chances are, you are doing things correctly. It is, of course, possible that you’re not doing it right or as frequently as is advisable, so it’s always worth mentioning your concern to your therapist so that it can be rectified if necessary.
“I’m back to square one” - you’ve learnt tools and techniques to help different aspects of the problem. Keep using them. The changes you’ve made are not wasted. You’re a different person now to when you first started the sessions, so you’ll find it easier to get back on it now because you know you can do it.
“I’m always going to feel this way.” - Up until this lapse, you felt a lot better. This shows you that you can change. That life can be better. Keep going and you will get there.
References:
Collins, L. M. (2006). Analysis of longitudinal data: The integration of theoretical model, temporal design, and statistical model. Annual Review of Psychology. 57, 505–528
Hayes, A. M., Laurenceau, J. P., Feldman, G., Strauss J. L. & Cardaciotto, L. (2007). Change is Not Always Linear: The Study of Nonlinear and Discontinuous Patterns of Change in Psychotherapy. Clin Psychol Rev. 27(6), 715–723
Ilardi, S. S. & Craighead, W. E. (1994). The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice. 1, 138–156
Kelso, J. A. S. (1997). Dynamic patterns: The self-organization of brain and behavior. The MIT Press
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
SThelen, E. & Smith, L. B. (1994). A dynamic systems approach to the development of cognition and action. Cambridge: MIT Press