Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial

Abstract

BackgroundMindfulness-based cognitive therapy (MBCT) is an evidence-based group-based psychological treatment in oncology, resulting in reduction of depressive and anxiety symptoms. Internet-based MBCT (eMBCT) has been found to be an effective alternative for MBCT. The therapeutic alliance (the bond between therapist and patient,) is known to have a significant impact on psychological treatment outcomes, including MBCT. A primary concern in the practice of eMBCT is whether a good therapeutic alliance can develop. Although evidence for the beneficial effect of therapist assistance on treatment outcome in internet-based interventions (IBIs) is accumulating, it is still unclear whether the therapeutic alliance is related to outcome in IBIs.ObjectiveThis study aimed to (1) explore whether early therapeutic alliance predicts treatment dropout in MBCT or eMBCT, (2) compare the development of the therapeutic alliance during eMBCT and MBCT, and (3) examine whether early therapeutic alliance is a predictor of the reduction of psychological distress and the increase of mental well-being at posttreatment in both conditions.MethodsThis study was part of a multicenter randomized controlled trial (n=245) on the effectiveness of MBCT or eMBCT for distressed cancer patients. The therapeutic alliance was measured at the start of week 2 (ie, early therapeutic alliance), week 5, and week 9. Outcome measures were psychological distress, measured with the Hospital Anxiety and Depression Scale, and mental well-being, measured with the Mental Health Continuum-Short Form.ResultsThe strength of early therapeutic alliance did not predict treatment dropout in MBCT or eMBCT (B=−.39; P=.21). Therapeutic alliance increased over time in both conditions (F2,90=16.46; Wilks λ=0.732; P<.001). This increase did not differ between eMBCT and MBCT (F1,91=0.114; P=.74). Therapeutic alliance at week 2 predicted a decrease in psychological distress (B=−.12; t 114=−2.656; P=.01) and an increase in mental well-being (B=.23; t 113=2.651; P=.01) at posttreatment. The relationship with reduction of psychological distress differed between treatments: a weaker early therapeutic alliance predicted higher psychological distress at posttreatment in MBCT but not in eMBCT (B=.22; t 113=2.261; P=.03).ConclusionsA therapeutic alliance can develop in both eMBCT and MBCT. Findings revealed that the strength of early alliance did not predict treatment dropout. Furthermore, the level of therapeutic alliance predicted reduced psychological distress and increased mental well-being at posttreatment in both conditions. Interestingly, the strength of therapeutic alliance appeared to be more related to treatment outcome in group-based MBCT than in eMBCT.Trial RegistrationClinicalTrials.gov NCT02138513; https://clinicaltrials.gov/ct2/show/NCT02138513

Internet-delivered Mindfulness-Based Cognitive Therapy for anxiety and depression in cancer survivors: Predictors of treatment response

“…Finally, of particular relevance for this program that was adapted from a face-to-face intervention to an internet-delivered intervention, we tested the significance of therapeutic alliance for treatment effect. Therapeutic alliance was not found to predict outcome response, which was contradictory to our hypothesis and the findings of the other study of iMBCT for cancer patients ( Bisseling et al, 2019b ). It is, however, in concordance with the trend described by Bisseling et al (2019b) where therapeutic alliance was less associated with outcome response in iMBCT compared to the face-to-face MBCT condition.…”

“…The WAI-C scale is designed to measure therapeutic alliance from the client's perspective and is based on Bordin's pantheoretical tripartite conceptualization of the therapeutic alliance, including bonds, goals, and tasks of the therapy ( Horvath and Symonds, 1991 ). Although originally developed to measure alliance in face-to-face therapy, the scale is widely used by others to assess the therapeutic alliance in internet-delivered interventions ( Pihlaja et al, 2018 ; Sucala et al, 2012 ; Bisseling et al, 2019b ). Internal consistency (Cronbach's α) was 0.915 in the present sample.…”

“…Despite these findings, evidence is contradictory on whether therapeutic alliance may have less impact on the outcome of internet-delivered interventions ( Pihlaja et al, 2018 ; Hadjistavropoulos et al, 2017 ; Bisseling et al, 2019a ). In a recent study investigating the effects of both face-to-face group-based MBCT and iMBCT on distress in cancer patients, higher therapeutic alliance predicted treatment response in the face-to-face-delivered MBCT ( Bisseling et al, 2019a ), but not the iMBCT ( Bisseling et al, 2019b ). Investigating the predicting effect of therapeutic alliance is highly relevant for future attempts to optimize iMBIs.…”

Bridging the distance: Continuing psycho‐oncological care via video‐consults during the COVID‐19 pandemic

“…While earlier research into internet-based therapies (these work through text-based communication within a developed program with video and audio-files) showed this could lead to a good working alliance, that was experienced as personal, 7 video-consults are experienced as more distant by most clients and therapists (see Table 1). It is the non-verbal contact during face-to-face sessions that helps clients to express what is most difficult for them, which is lacking in video consults.…”

Therapist behaviours in a web-based mindfulness-based cognitive therapy (eMBCT) for chronic cancer-related fatigue – Analyses of e-mail correspondence

“…However, little is known about what the support of the therapist in web-based treatments entails. What we do know is that a therapeutic alliance develops in time in both MBCT and eMBCT, and that in both conditions the level of therapeutic alliance can predict reduced psychological distress and increased mental well-being post-treatment ( Bisseling et al, 2019 ). Furthermore, Sanchez-Ortiz et al (2011) stated that the communication from the therapist to the patient in Internet-based Cognitive Behavioural Therapy (ICBT) is mainly supportive in content rather than psychoeducational.…”