Skip to main content

Advertisement

Log in

(Inter)personal Computing: The Role of the Therapeutic Relationship in E-mental Health

  • Original Paper
  • Published:
Journal of Contemporary Psychotherapy Aims and scope Submit manuscript

Abstract

E-mental health technologies are rapidly expanding the reach of psychological interventions around the globe. There is a growing evidence base supporting the potential benefits of these new technologies for psychological and behavioural health. Most of this evidence to date has focused on evaluating the feasibility and outcomes from such interventions, whilst limited research has begun to explore the change processes associated with their impact. In traditional psychological therapies the quality of common factors, including the therapeutic relationship, are widely held to be important for engagement and outcomes. E-mental health interventions present a challenge to the importance of these factors, as therapeutic interactions are typically remote, limited, or even absent in the case of fully automated e-mental health programmes. This paper explores the role of the therapeutic relationship in e-mental health. Where measured, it appears that the relationship is fairly robust to distance and limited contact, but may be less intimately associated with therapy outcomes than in traditional therapies. Where the intervention comprises little or no therapeutic contact, we explore how some of the variance in engagement and outcomes may still be accounted for by common and relational factors offered through a supportive frame or embedded within the technologies themselves. Implications for theory, research and practice are presented.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  • Andersson, G. (2009). Using the internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47, 175–180.

    Article  PubMed  Google Scholar 

  • Andersson, G., Carlbring, P., Berger, T., Almlöv, J., & Cuijpers, P. (2009). What makes internet therapy work? Cognitive Behaviour Therapy, 38, 55–60.

    Article  PubMed  Google Scholar 

  • Andersson, G., Paxling, B., Wiwe, M., Vernmark, K., Felix, C. B., Lundborg, L., et al. (2012). Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder. Behaviour Research and Therapy, 50, 544–550. doi:10.1016/j.brat.2012.05.003.

    Article  PubMed  Google Scholar 

  • Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS ONE, 5, e13196.

    Article  PubMed  Google Scholar 

  • Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., et al. (2012). Videoconferencing psychotherapy: A systematic review. Psychological services, 9, 111.

    Article  PubMed  Google Scholar 

  • Barazzone, N., Cavanagh, K., & Richards, D. A. (2012). Computerized cognitive behavioural therapy and the therapeutic alliance: A qualitative enquiry. British Journal of Clinical Psychology, 51(4), 396–417.

    Article  PubMed  Google Scholar 

  • Bauer, S., Okon, E., Meermann, R., & Kordy, H. (2012). Technology-enhanced maintenance of treatment gains in eating disorders: Efficacy of an intervention delivered via text messaging. Journal of Consulting and Clinical Psychology, 80, 700–706. doi:10.1037/a0028030.

    Article  PubMed  Google Scholar 

  • Bergman Nordgren, L., Carlbring, P., Linna, E., & Andersson, G. (2013). Role of the working alliance on treatment outcome in tailored internet-based cognitive behavioural therapy for anxiety disorders: Randomized controlled pilot trial. JMIR Research Protocols, 2(1), e4.

    Article  PubMed  Google Scholar 

  • Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 13–37). New York: Wiley.

    Google Scholar 

  • Cartreine, J. A., Ahern, D. K., & Locke, S. E. (2010). A roadmap to computer-based psychotherapy in the United States. Harvard Review of Psychiatry, 18(2), 80–95.

    Article  PubMed  Google Scholar 

  • Cavanagh, K. (2010). Turn on, tune in and (don’t) drop out: Engagement, adherence, attrition, and alliance with internet-based interventions. In J. Bennett-Levy, D. A. Richards, P. Farrand, H. Christensen, K. M. Griffiths, D. J. Kavanagh. C. Williams (Eds.), Oxford guide to low intensity CBT interventions (pp. 227–233). New York: Oxford University Press.

  • Cavanagh, K. (2013). The geography of cognitive behavioural therapy: Ten year on. Behavioural and Cognitive Psychotherapy (in press).

  • Cavanagh, K. & Millings, A. (2013). Increasing engagement with computerised cognitive behavioural therapies. Ambient Systems (in press).

  • Cavanagh, K., Zack, J., & Shapiro, D. (2003). Empirically supported computerized psychotherapies. Telepsychiatry and e-mental health. London: RSM Press.

    Google Scholar 

  • Chu, B. C., Choudhury, M. S., Shortt, A. L., Pincus, D. B., Creed, T. A., & Kendall, P. C. (2005). Alliance, technology, and outcome in the treatment of anxious youth. Cognitive and Behavioral Practice, 11, 44–55.

    Article  Google Scholar 

  • Clough, B. A., & Casey, L. M. (2011). Technological adjuncts to increase adherence to therapy: A review. Clinical Psychology Review, 31, 697–710.

    Article  PubMed  Google Scholar 

  • Cuijpers, P., Donker, T., Johansson, R., Mohr, D. C., van Straten, A., & Andersson, G. (2011). Self-guided psychological treatment for depressive symptoms: A meta-analysis. PLoS ONE, 6, e21274.

    Article  PubMed  CAS  Google Scholar 

  • Cuijpers, P., Donker, T., van Straten, A., & Andersson, G. (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A meta-analysis of comparative outcome studies. Psychological Medicine, 40, 1943–1957.

    Article  PubMed  CAS  Google Scholar 

  • Cuijpers, P., Marks, I., van Straten, A.-M., Cavanagh, K., Gega, L., & Andersson, G. (2009). Computer-aided psychotherapy for anxiety disorders: A meta-analytic review. Cognitive Behaviour Therapy, 38, 66–82.

    Article  PubMed  Google Scholar 

  • Gega, L., Smith, J., & Reynolds, S. (2013). Cognitive behaviour therapy (CBT) for depression by computer versus therapist: Patient experiences and therapeutic processes. Psychotherapy Research, 23(2), 1–14.

    Article  Google Scholar 

  • Glasgow, R. E., & Rosen, G. M. (1978). Psychological Bulletin, 85(1), 1–23.

    Article  PubMed  CAS  Google Scholar 

  • Griffiths, K. M., Calear, A. L., Banfield, M., & Tam, A. (2009). Systematic review on internet support groups (ISGs) and depression (2): What is known about depression ISGs? Journal of Medical Internet Research, 11, e41. doi:10.2196/jmir.1303.

    Article  PubMed  Google Scholar 

  • Grist, R., & Cavanagh, K. (2013). Computerised cognitive behavioural therapy for common mental health disorders, what works, for whom under what circumstances? A systematic review and meta-analysis. Journal of Contemporary Psychotherapy. doi:10.1007/s10879-013-9243-y.

    Google Scholar 

  • Hanley, T., & Reynolds, D. (2009). Counselling psychology and the internet: A review of the quantitative research into online outcomes and alliances within text-based therapy. Counselling Psychology Review, 24, 4–13.

    Google Scholar 

  • Helgadóttir, F. D., Menzies, R. G., Onslow, M., Packman, A., & O’Brian, S. (2009). Online CBT I: Bridging the gap between Eliza and modern online CBT treatment packages. Behaviour Change, 26, 245–253.

    Article  Google Scholar 

  • Hollinghurst, S., Peters, T. J., Kaur, S., Wiles, N., Lewis, G., & Kessler, D. (2010). Cost-effectiveness of therapist-delivered online cognitive—behavioural therapy for depression: Randomised controlled trial. British Journal of Psychiatry, 197, 297–304.

    Article  PubMed  Google Scholar 

  • Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21–37.

    Article  Google Scholar 

  • Kenwright, M. (2010). Introducing and supported written and internet-based guided CBT. In J. Bennett-Levy, D. A. Richards, P. Farrand, H. Christensen, K. M. Griffiths, D. J. Kavanagh & C. Williams (Eds.), Oxford guide to low intensity CBT interventions (pp. 105–112). New York: Oxford University Press.

  • Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., et al. (2009). Therapist-delivered internet psychotherapy for depression in primary care: A randomised controlled trial. The Lancet, 374(9690), 628–634.

    Article  Google Scholar 

  • Kraft, P., Drozd, F., & Olsen, E. (2009). ePsychology: Designing theory-based health promotion interventions. Communications of the Association for Information Systems, 24, 399–426.

    Google Scholar 

  • Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38, 357–361.

    Google Scholar 

  • Leahy, R. L. (2008). The therapeutic relationship in cognitive-behavioral therapy. Behavioural and Cognitive Psychotherapy, 36(6), 769.

    Article  Google Scholar 

  • Liess, A., Simon, W., Yutsis, M., Owen, J. E., Piemme, K. A., Golant, M., et al. (2008). Detecting emotional expression in face-to-face and online breast cancer support groups. Journal of Consulting and Clinical Psychology, 76, 517–522.

    Article  PubMed  Google Scholar 

  • Macneil, C. A., Hasty, M. K., Evans, M., Redlich, C., & Berk, M. (2009). The therapeutic alliance: Is it necessary or sufficient to engender positive outcomes? Acta Neuropsychiatrica, 21, 95–98. doi:10.1111/j.1601-5215.2009.00372.x.

    Article  Google Scholar 

  • Marks, I. M., & Cavanagh, K. (2009). Computer-aided psychological treatments: Evolving issues. Annual Review of Clinical Psychology, 5, 97–119.

    Article  Google Scholar 

  • Marks, I. M., Cavanagh, K., & Gega, L. (2007). Hands-on help: Computer-aided psychotherapies. Maudsley monograph no. 49. Hove: Psychology Press.

    Google Scholar 

  • Martin, D. J., Graske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

    Article  PubMed  CAS  Google Scholar 

  • Mason, J. (2011). Cognitive engagement and questioning online. Education in a technological world: communicating current and emerging research and technological efforts. Formatex, Badajoz, Spain.

  • Mohr, D. C., Cuijpers, P., & Lehman, K. (2011). Supportive accountability: A model for provising human support to enhance adherence to e-health interventions. Journal of Internet Medical Research, 13, e30. doi:10.2196/jmir.1602.

    Article  Google Scholar 

  • Morris, M. E., & Aguilera, A. (2012). Mobile, social, and wearable computing and the evolution of psychological practice. Professional Psychology: Research and Practice, 43, 622–626.

    Article  Google Scholar 

  • Muñoz, R. F. (2010). Using evidence-based internet interventions to reduce health disparities worldwide. Journal of Medical Internet Research, 12, e60. doi:10.2196/jmir.1463.

    Article  PubMed  Google Scholar 

  • Newman, M. G., Szkodny, L. E., Llera, S. J., & Przeworski, A. (2011). A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: Is human contact necessary for therapeutic efficacy? Clinical Psychology Review, 31, 89–103.

    Article  PubMed  Google Scholar 

  • NICE (2011). Common mental health disorders. Identification and pathways to care. Clinical guidance 123. London : National Institute of Health and Clinical Excellence.

  • Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York: Oxford University Press.

    Google Scholar 

  • Ormrod, J., Kennedy, L., Scott, J., & Cavanagh, K. (2010). Therapeutic alliance and computer aided cognitive behavioural therapy. Cognitive Behavioural Therapy. doi:10.1080/16506071003675614.

    Google Scholar 

  • Overholser, J. C. (2011). Collaborative empiricism, guided discovery, and the Socratic method: Core processes for effective cognitive therapy. Clinical Psychology: Science and Practice, 18(1), 62–66.

    Article  Google Scholar 

  • Peck, D. F. (2010). The therapist–client relationship, computerized self-help and active therapy ingredients. Clinical Psychology & Psychotherapy, 17(2), 147–153.

    Google Scholar 

  • Preschl, B., Maercker, A., & Wagner, B. (2011). The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression. BMC Psychiatry, 11, 189–199.

    Article  PubMed  Google Scholar 

  • Proudfoot, J., Swain, S., Widmer, S., Watkins, E., Goldberg, D., Marks, I., et al. (2003). The development and beta-test of a computer-therapy program for anxiety and depression: Hurdles and lessons. Computers in Human Behavior, 19, 277–289.

    Article  Google Scholar 

  • Richards, D., & Richardson, T. (2012). Computer-based psychological interventions for depression treatment: A systematic review and meta-analysis. Clinical Psychology Review, 32, 329–342.

    Article  PubMed  Google Scholar 

  • Richards, D., Timulak, L & Hevey, D. (2012). A comparison of two online cognitive-behavioural interventions for symptoms of depression in a student population: The role of therapist responsiveness. Counselling and Psychotherapy Research. doi:10.1080/14733145.2012.733715.

  • Richardson, R., & Richards, D. A. (2006). Self-help: Towards the next generation. Behavioural and Cognitive Psychotherapy, 34(01), 13–23.

    Article  Google Scholar 

  • Richardson, R., Richards, D. A., & Barkham, M. (2010). Self-help books for people with depression: The role of the therapeutic relationship. Behavioural and Cognitive Psychotherapy, 38, 67–81.

    Article  PubMed  Google Scholar 

  • Riper, H., Andersson, G., Christensen, H., Cuijpers, P., Lange, A., & Eysenbach, G. (2010). Theme issue on e-mental health: A growing field in internet research. Journal of Medical Internet Research, 12, e74.

    Article  PubMed  Google Scholar 

  • Robinson, E., Titov, N., Andrews, G., McIntyre, K., Schwencke, G., & Solley, K. (2010). Internet treatment for generalized anxiety disorder: A randomized controlled trial comparing clinician versus technician assistance. PLoS ONE, 5, e10942.

    Article  PubMed  Google Scholar 

  • Rochlen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269–283.

    Article  PubMed  Google Scholar 

  • Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., et al. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47(11), 902–909.

    Article  PubMed  CAS  Google Scholar 

  • Shoham, V., & Insel, T. R. (2011). Rebooting for whom? Portfolios, technology, and personalized intervention. Perspectives on Psychological Science, 6, 478–482.

    Article  Google Scholar 

  • Spek, V., Cuipers, P., Nyklicek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37, 319–328.

    Article  PubMed  Google Scholar 

  • Stern, S. (1993). Managed care, brief therapy, and therapeutic integrity. Psychotherapy: Theory, Research, Practice, Training, 30, 162.

    Article  Google Scholar 

  • Sucala, M., Schnur, J. B., Constantino, M. J., Miller, S. J., Brackman, E. H., & Montgomery, G. H. (2012). The therapeutic relationship in e-therapy for mental health: A systematic review. Journal of Medical Internet Research, 14(4), e110.

    Article  PubMed  Google Scholar 

  • Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship construct. Clinical Psychology: Science and Practice, 18, 47–61.

    Article  Google Scholar 

  • Titov, N., Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010). Internet treatment for depression: A randomized controlled trial comparing clinician versus technician assistance. PLoS ONE, 5(6), e10939.

    Article  PubMed  Google Scholar 

  • Wagner, B., Brand, J., Schulz, W., & Knaevelsrud, C. (2012). Online working alliance predicts treatment outcome for posttraumatic stress symptoms in arab war-traumatized patients. Depression and Anxiety, 29, 646–651. doi:10.1002/da.21962.

    Article  PubMed  Google Scholar 

  • Williams, C., & Martinez, R. (2008). Increasing access to CBT: Stepped care and CBT self-help models in practice. Behavioural and Cognitive Psychotherapy, 36, 675–683.

    Article  Google Scholar 

  • Wright, J. H., Wright, A. S., Albano, A. M., Basco, M. R., Raffield, T., & Otto, M. W. (2005). Computer-assisted cognitive therapy for depression: Maintaining efficacy while reducing therapist time. American Journal of Psychiatry, 162, 1158–1164.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kate Cavanagh.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Cavanagh, K., Millings, A. (Inter)personal Computing: The Role of the Therapeutic Relationship in E-mental Health. J Contemp Psychother 43, 197–206 (2013). https://doi.org/10.1007/s10879-013-9242-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10879-013-9242-z

Keywords

Navigation