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With organizations and clinicians making decisions about their immediate futures with telehealth, new research regarding the role of telehealth therapeutic alliance outcomes is particularly pertinent. In line with numerous studies demonstrating that many telehealth services produce outcomes that are similar to in-person treatment (Krzyzaniak et al., 2021; Thomas et al., 2021), questions remain about how telehealth can be used to develop and maintain a strong therapeutic alliance between patients and providers (Simpson & Reid, 2014).
Alternatively referred to as the working alliance, the helping alliance, or the alliance, a therapeutic alliance used herein refers to the therapeutic activities that strengthen the quality and collaborative aspects of the client-therapist or patient-provider relationship (Flückiger et al., 2018; Horvath et al., 2011). Such an alliance is believed to reflect relationship qualities and facilitative conditions that contribute to change in behavioral health treatment. Contributing factors include acceptance, empathy, openness, and a collaborative partnership (Agnew-Davies et al., 1998). In early writings about the therapeutic alliance, Bordin (1979) outlined three contributing components: agreement on therapeutic goals, agreement on therapeutic tasks, and a positive bond.
Telehealth Therapeutic Alliance Research
Although much has been published about telehealth, less is known about the quality of therapeutic relationships in a virtual setting. A 2022 study published in the Journal for Technology in Behavioral Science by Sara J. Sagui-Henson and colleagues studied the components of the therapeutic alliance (a mechanism posited to underly successful treatment) and their association with positives. The study examined (1) participant ratings of components of the therapeutic alliance with virtual providers, (2) changes in subjective well-being and depressive symptoms in clients with positive scores on a depression measure, and (3) the association between alliance and participants’ well-being.
The study included 3,087 adults, with a median age of 36 ± 9 years, in a sample that was 54% female.
Participants had digital access to these types of professionals using videoconference sessions between 9/29/2020 and 9/12/21:
- Licensed therapist (18%)
- Certified coach (65%)
- Both (17%)
The Working Alliance Inventory and the World Health Organization-Five (WHO-5) Well-Being Index scores were used to measure changes. Descriptive and inferential statistics were used to assess alliance ratings across demographics, utilization types, and the association between alliance and well-being.
Goals of Study
The researchers examined components of therapeutic alliance and the association with well-being outcomes among people with access to employer-sponsored teletherapy and telecoaching during the COVID-19 pandemic. Participants engaged in videoconference sessions with therapists, coaches, or providers. They evaluated participant-rated alliance components, subjective well-being and depressive symptoms, and session utilization over time. Their research aims were:
- Evaluate participant ratings of components of the therapeutic alliance with providers in a virtual setting
- Examine changes in subjective well-being and depressive symptoms among participants who screened positive for depressive symptoms at baseline, and
- Explore the association between components of alliance and changes in participants’ well-being.
In examining telehealth therapeutic alliance in adults receiving care via videoconferencing, the researchers found that telecoaching and teletherapy via videoconferencing can support a telehealth therapeutic alliance. They mentioned that the virtual format might enhance rather than diminish the strong bonds and mutually agreed-upon goals formed with coaches and therapists. They explained that videoconferencing creates a neutral and collaborative environment by facilitating care in a familiar setting for the client. They posited that it may also provide a greater sense of intimacy and personal control, increasing client comfort and investment in the therapy process (Simpson & Reid, 2014). They also noted that tailoring care recommendations to people’s clinical needs and personal preferences for a type of provider might be a practical approach to fostering good therapeutic relationships. They suggest that digital mental health services find ways to systematically assess client-provider therapeutic alliance over time to ensure high-quality care delivery.
Regarding their second goal, the reported rates of improvement in their participants are in line with prior work evaluating the use of videoconferencing to deliver individual psychotherapy (Thomas et al., 2021) and recovery rates for depression in working-age adults in stratified stepped care delivery models (Firth et al., 2015).
Their third goal for this study involved participants who screened positive for depressive symptoms at baseline. Higher therapeutic alliance scores were associated with greater well-being at follow-up. This finding reinforces prior work that the therapeutic alliance contributes to beneficial treatment outcomes in videoconferencing settings (Pihlaja et al., 2018). This study also supported previous reports of client preference and high satisfaction for videoconferencing telehealth (Thomas et al., 2021) and points to a continued trend toward expanding telemental health services after the COVID-19 pandemic (Smith et al., 2020). The study shows that clients and providers can establish high-quality telehealth therapeutic alliances. The authors expressed the hope that their study will positively impact the most significant barrier to telehealth, that of low practitioner adoption before COVID, attributed to hesitations that technology inhibits therapeutic processes (Cowan et al., 2019; Guinart et al., 2021). As stated in the article, the researchers suggest that:
These and other findings should give providers confidence that they can create a collaborative relationship that supports clients’ treatment experience when they are face-to-face but not physically in the same space.
Some of the more salient results of this study included:
- The median adapted therapeutic alliance score was 4.8 from 1–5.
- Scores did not differ by age, country, or baseline well-being.
- Women reported higher components of alliance than men.
- Telecoaching participants reported higher alliance components than those utilizing teletherapy or both telecoaching and teletherapy.
- Participants with elevated baseline depressive symptoms (835) reported clinical recovery or clinical improvement in depressive symptoms.
- Higher telehealth therapeutic alliance scores predicted greater well-being at follow-up after controlling for age, sex, baseline WHO-5, and the number of days in care).
- Exploratory analyses indicated that this association did not differ by utilization type, baseline well-being, or session utilization (Ps > .34).
- People with access to one-on-one videoconferencing formed a strong bond and sense of alignment on goals with both coaches and therapists.
- Alliance scores were associated with improvements in subjective well-being among participants who began care with elevated depressive symptoms, suggesting that a positive bond and goal alignment with a provider influence virtual care outcomes.
- Continued focus on the quality of therapeutic relationships will ensure digital mental health services are patient-tailored as these platforms expand equitable access to evidence-based care.
The researchers explained that focusing on the components of the telehealth therapeutic alliance is important because of the following:
- The global gaps in the behavioral health workforce (Health Resources & Services Administration/National Center for Health Workforce Analysis, 2015)
- There is an unprecedented demand for mental health services.
- Practitioner shortages are forcing the expansion of the criteria for who can provide care, including virtual care.
- This expansion includes paraprofessionals and other individuals who can develop an alliance that helps lead to behavior change and better outcomes.
The authors conclude their study comparing a telehealth therapeutic alliance with an in-person therapeutic alliance by making the following statement:
Technology-enabled mental health services have the potential to transform how evidence-based care is delivered to be more equitable. The use of videoconferencing to deliver mental health treatment is evolving. It will likely play a significant role in addressing the needs of people affected by global crises, so ensuring quality is key. This study demonstrated that individuals using teletherapy and telecoaching services through an employer-sponsored mental health benefit reported similarly high ratings of the therapeutic alliance with both types of providers, which was a factor that led to effective treatment. This may challenge assumptions that in-person treatment is the only modality through which high-quality relationships can be formed and provokes consideration or reconsideration of the credibility for videoconferencing as a valuable therapeutic medium. It also highlights the importance of tailoring care recommendations to the individual to achieve strong relationships and outcomes.
in time, this and other studies of telehealth therapeutic alliance would be strengthened by being replicated with an in-person comparison group in a perfect world where COVID is not at play.
This article is part of the Open-Access program offered by Springer Health, publisher of the Journal for Technology in Behavioral Science. The article is available at no charge.
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