Connecting over the internet: Establishing the therapeutic alliance in an internet-based treatment for depressed adolescents

Abstract

Internet-based treatments have been developed for youth mental health difficulties, with promising results. However, little is known about the features of therapeutic alliance, and how it is established and maintained, in text-based interactions between adolescents and therapists in internet-based treatments. This study uses data collected during a pilot evaluation of a psychodynamic internet-based therapy for depressed adolescents. The adolescents had instant-messaging chats with their therapists once a week, over 10 weeks. The adolescents also rated the therapeutic alliance each week, using the Session Alliance Inventory. The present study uses qualitative methods to analyse transcripts of text-based communication between the young people and their therapists. The aim is to identify and describe the key features of therapeutic alliance, and reflect upon the implications for theory and clinical practice. Analysis identified three ‘values’ that may underpin a strong therapeutic alliance: togetherness, agency and hope. A number of therapist techniques were also found, which seemed to create a sense of these values during text-chat sessions. These findings are discussed, alongside implications for future research.

“I didn’t have to look her in the eyes”—participants’ experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

“…However, these experiences are less present in studies on internet-based treatments. Mortimer et al (2022) analyzed chat sessions for adolescent IPDT and discussed the importance of the therapist presenting themselves as a real person with a mind of their own. This was done by referring to one's own mental state, highlighting joint work, and by expressing care and positivity.…”

“…They briefly described experiences of the therapeutic relationship, and its main benefit was described as being helpful in supporting the program or individualizing goals rather than a relationship being important in its own right. Mortimer et al (2022) analyzed transcripts of communication between adolescents in IPDT for depression and their therapists, finding three core values that seemed important for the alliance: togetherness, hope, and agency. To our knowledge, no studies have focused on experiences of the therapeutic relationship in IPDT in either adult or adolescent populations.…”

The alliance with young people: Where have we been, where are we going?

“…To be more developmentally appropriate and clinically relevant some have argued that alliance definition(s) (and measures) should describe this key therapy variable according to what young clients and therapists report as being important to them (Bedi, 2006; Horvath, 2011). Some recent attempts to qualitatively explore young people’s experience of the therapeutic relationship point to the importance of developing trust and emotional closeness for the development of a good alliance (Cirasola, Martin, et al, 2022; Mortimer et al, 2022). Furthermore, especially with adolescents, respect for their individuality, agency, and confidentiality have been found to be key aspects of a strong alliance (Gulliver et al, 2010; Wilmots et al, 2020).…”

“…To do so, it is crucial to learn more about how to build a good alliance when working with young people, especially in internet-based therapy, since many of the techniques used in face-to-face therapy, such as body language, cannot be relied upon online (Wood et al, 2021). A qualitative study exploring the role of the alliance in text-based psychodynamic psychotherapy for adolescents identified the “supportive” techniques of praise, warmth, and creating a sense of hope as being important for building a strong alliance (Mortimer et al, 2022). Therapists working remotely with young people might, thus, need to be even more explicit in demonstrating their support and positive regard verbally to form a good alliance, compared to those working face to face, where alliance-building may depend more on nonverbal cues.…”

“…In recent years, since internet-based interventions have shown promising results for adolescents (Christ et al, 2020; Grist et al, 2019; Midgley et al, 2021), a small body of research has begun to examine associations between alliance and outcome in online therapy too (Anderson et al, 2012; Hanley, 2012; Henson et al, 2019; Mortimer et al, 2022). Despite the small number of studies, research has thus far supported the existence of an association between alliance and outcome in internet-based therapy for adolescents (Anderson et al, 2012; Mortimer et al, 2022). Since most western adolescents live within sophisticated online worlds internet-based therapy might be an effective option for them (Pagnotta et al, 2018), and fostering an alliance remotely might need to be a clinical priority.…”