Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder
Highlights
► We studied therapeutic alliance in Internet-delivered cognitive behaviour therapy (ICBT). ► Therapeutic alliance does not seem to play any major role in ICBT. ► The findings are important as they add to the literature on alliance and CBT.
Introduction
The concept of therapeutic alliance, also known as the working alliance, is often regarded as an important ingredient in psychotherapy across different psychotherapy orientations (Lambert & Barley, 2002), but has been studied to a lesser extent in alternative treatment formats such as group therapy and guided self-help. Bordin (1979) introduced a model for understanding therapeutic alliance in which he made distinctions between task, goal and bond, which together form the concept of alliance (Bordin, 1979).
During the last 15 years there has been a rapid development of new ways to deliver cognitive behaviour therapy (CBT), and of these new approaches the internet has probably been the format with the most studies (Andersson, 2009). Many studies on internet-delivered CBT (ICBT) have involved guidance which tends to boost the effect (Andersson & Cuijpers, 2009; Spek, Cuijpers et al., 2007), usually to the extent that guided ICBT and face-to-face therapy yield equivalent outcomes (Bergström et al., 2010; Hedman et al., 2011). Equal outcomes have been found in studies on panic disorder (Bergström et al., 2010; Carlbring et al., 2005; Kiropoulos et al., 2008), social anxiety disorder (Andrews, Davies, & Titov, 2011; Hedman et al., 2011), and subclinical depression (Spek, Nyklicek et al., 2007), but also in studies on conditions like tinnitus (Kaldo et al., 2008).
The role of the therapeutic alliance in guided ICBT is not obvious as there is much less therapist contact than in face-to-face treatments (approximately 1/10 of the time), and that the client may not even see the therapist in person. Still there is a therapeutic interaction as the therapist responds to messages sent from the client and uses both specific and common factors to encourage the client to work with the ICBT (Paxling et al., in press). The development of a therapeutic alliance may not necessarily require direct face-to-face contact with a therapist. It is possible that alliance is at least partly based on client expectations regarding both tasks and goals that may exist before the therapy starts. While the bond between the therapist and the client probably is different in ICBT than in face-to-face therapy questions regarding task, goal and bond are still relevant. Therefore we believe that a therapeutic alliance can be formed over the internet as the therapist in ICBT provides individualized encouragement on progress and also responds to difficulties the client may confront when working with self-help material. Moreover, self-help texts can include aspects that help form a therapeutic alliance and a client may perceive an understanding clinician who is behind the text material (Richardson, Richards, & Barkham, 2010). In other words the total information available for clients when rating the alliance can consist of interactions with a therapist online, interactions with a treatment system, and text material that can possibly boost the alliance.
There has been some previous research on the role of alliance in internet treatments. Cook and Doyle (2002) studied alliance ratings in a small sample (N = 15) and compared the ratings with those from a previous study sample who had received face-to-face therapy. Contrary to expectations the client rated alliance was higher in the online therapy group (Cook & Doyle, 2002). This finding was replicated in a study on e-mail counselling in which the authors found high ratings of alliance (D'Arcy, Reynolds, Stiles, & Grohol, 2006), that were within the range of what has been found in face-to-face studies. A limitation of both studies is the lack of a control group as they used previously reported results for the face-to-face comparisons. In a study on posttraumatic stress disorder (PTSD) Knaevelsrud and Maercker (2006) found high ratings of alliance, even if alliance was not a strong predictor of outcome (Knaevelsrud & Maercker, 2006). However in a subsequent report, the same authors found that alliance scores increased during treatment and that ratings of alliance at the end of treatment correlated with treatment outcome (N = 41) (Knaevelsrud & Maercker, 2007). Klein, Austin, et al. (2009) and Klein, Mitchell et al. (2009) studied the role of frequency of therapist e-mail contact in a trial on panic disorder. They found no differences in client alliance ratings between the intensive contact condition (average therapist time 308 min) versus the infrequent contact condition (average therapist time 205 min) (Klein, Austin et al., 2009). The authors concluded that the time spent with the therapist may not be a key variable when rating alliance. Overall, ratings of alliance were high, which the same researchers also found in another study on posttraumatic stress disorder (Klein, Mitchell, et al., 2009). Correlations with outcome were not reported.
In light of the previous findings which indicate that alliance can be formed in ICBT we wanted to investigate alliance ratings by clients who were research participants in three different ICBT programs. The first was a study on ICBT for depression (Vernmark et al., 2010) in which internet-delivered guided self-help was compared with e-mail therapy. Ratings of therapeutic alliance were collected from the participants between week 3 and 4 of the treatment. The second data set was from a controlled trial on ICBT for generalized anxiety disorder (GAD), in which guided ICBT was tested against a waiting-list control group (Paxling et al., 2011). Alliance ratings were collected during the third treatment week. The third data set was derived from a study on social anxiety disorder (SAD), in which ICBT was tested against a waiting-list control group who participated in an online discussion forum (Andersson, Carlbring, Furmark, & on behalf of the SOFIE Research Group, 2012). Alliance ratings were collected at the beginning of the fourth treatment week. We expected high ratings of alliance and investigated if ratings of alliance would be predictive of treatment outcome.
Section snippets
Background
Data were collected in association with a controlled study on ICBT for major depression (Vernmark et al., 2010). All participants were interviewed live, but self-report instruments including alliance ratings were collected via the internet. Treatment was provided on the internet and each participant had an online therapist who followed them for the full 8 week treatment period.
Procedure
A total of 88 persons with a confirmed diagnosis of major depression (American Psychiatric Association, 2000) were
Background
Data in sample II were collected during a controlled study on ICBT for GAD (Paxling et al., 2011). Participants were screened online and thereafter interviewed over the telephone. As in sample I, self-report instruments and alliance ratings were collected via the internet. Treatment was provided via the internet and each participant had an online therapist who guided them through the 8 week treatment period.
Procedure
Following screening and interview we included 89 persons diagnosed with GAD (American
Background
Data for sample III were collected in association with a controlled study on ICBT for SAD (Andersson, Carlbring, & Furmark, & on behalf of the SOFIE Research Group, 2012). Similar to the sample II participants were screened online and then interviewed over the telephone to obtain a DSM-IV diagnosis of social phobia (American Psychiatric Association, 2000). Self-report instruments including the short WAI were collected online. The guided ICBT treatment lasted for 9 weeks and each participant had
Discussion
The aim of this study was to investigate the role of therapeutic alliance in guided ICBT. We included data from three study samples diagnosed with major depression, generalized anxiety disorder, or social anxiety disorder. The rationale for the study was that guided ICBT has been found to be effective (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010), but the mechanisms driving the effects are largely unknown (Andersson, 2010). Therapeutic alliance is often regarded as an important factor in
Acknowledgements
This research was sponsored in part by grants from the Swedish council for working and life research, the Swedish research council, and Linköping University. We thank all coworkers in the Klara, Origo and Sofie 6 trials for the contributions.
References (62)
Using the internet to provide cognitive behaviour therapy
Behaviour Research and Therapy
(2009)- et al.
The Liebowitz social anxiety scale as a self-report instrument: a preliminary psychometric analysis
Behaviour Research and Therapy
(2002) - et al.
Internet vs. paper and pencil administration of questionnaires commonly used in panic/agoraphobia research
Computers in Human Behavior
(2007) - et al.
Treatment of panic disorder: live therapy vs. self-help via Internet
Behaviour Research and Therapy
(2005) - et al.
A radical behavioral understanding of the therapeutic relationship in effecting change
Behavior Therapy
(1996) - et al.
Internet administration of self-report measures commonly used in research on social anxiety disorder: a psychometric evaluation
Computers in Human Behavior
(2010) - et al.
Internet versus group cognitive-behavioral treatment of distress associated with tinnitus. A randomised controlled trial
Behavior Therapy
(2008) - et al.
Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial
Lancet
(2009) - et al.
Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT?
Journal of Anxiety Disorders
(2008) - et al.
Development and validation of the Penn state worry questionnaire
Behaviour Research and Therapy
(1990)