Whereas sudden gains and losses (large shifts in symptom severity) in patients receiving psychotherapy appear abrupt and hence may seem unexpected, hypotheses from complex-systems theory suggest that sudden gains and losses are actually preceded by certain early-warning signals (EWSs). We tested whether EWSs in patients’ daily self-ratings of the psychotherapeutic process predicted future sudden gains and losses. Data were collected from 328 patients receiving psychotherapy for mood disorders who completed daily self-ratings about their therapeutic process using the Therapy Process Questionnaire (TPQ). Sudden gains and losses were classified from the Problem Intensity scale of the TPQ. The other items of the TPQ were used to compute the EWSs. EWSs predicted an increased probability for sudden gains and losses in a 4-day predictive window. These results show that EWSs can be used for real-time prediction of sudden gains and losses in clinical practice.

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Objective: The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder.Methods: A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the client's dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the client's individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions.Results: For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy.Conclusion: By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and toward a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.