The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial

Abstract

Background Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. Objective The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. Methods A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. Results We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P<.001) and patient well-being (γ02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68). Conclusions The results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

Therapeutic Relationship in eHealth—A Pilot Study of Similarities and Differences between the Online Program Priovi and Therapists Treating Borderline Personality Disorder

“…These findings are in line with earlier qualitative pilot studies on how BPD patients experience online interventions, which report good acceptance, satisfaction, and usability of online tools [ 13 , 14 , 15 ] and good WAI ratings for technological interventions [ 25 , 26 , 27 , 28 ].…”

“…It should be noted that most of the studies included in that meta-analysis targeted guided internet interventions, where an internet-based program is combined with regular support by a therapist and focused the alliance between patient and supporting therapist. Some studies also assessed the therapeutic relationship of patients with the online intervention itself and suggest that patients are in fact able to form a therapeutic alliance with a technology-based intervention [ 25 , 26 , 27 , 28 , 29 ]. One study implies, though, that this alliance may be different from the alliance to the therapist.…”

Working Alliance Inventory for Online Interventions-Short Form (WAI-TECH-SF): The Role of the Therapeutic Alliance between Patient and Online Program in Therapeutic Outcomes

“…However, this structure is inconsistent with the three-dimensional structure of Bordin’s [ 4 ] theory and the original validation of the WAI-SF carried out by Hatcher and Gallispy [ 16 ] to measure TA in the face-to-face context, distinguishing three separate factors: tasks, goals, and bonds. Nevertheless, the structure of this questionnaire is controversial because a bi-factorial structure has also been found in other validations of the WAI, such as in Gómez-Penedo et al [ 24 ], who found that in the TA with the therapist in IBIs, “goals and tasks” loaded in the same factor, whereas “bond” loaded in a separate factor. According to our findings, a three-dimensional structure cannot be assumed a priori in the context of IBIs.…”

“…Nonetheless, a systematic review showed an effect of TA on anxiety and depressive outcomes, pointing out that higher levels of TA were related to better clinical outcomes [ 23 ]. Recently, Gómez-Penedo et al [ 24 ] explored the reliability and validity of the WAI-SF in guided IBIs, taking into account the relational aspects involved in this type of intervention (e.g., therapist support, online program). In this validation, the bond subscale was adapted to refer to the acceptance and trust between the patient and the therapist who supported him/her in the online program.…”

“…To do so, an adaptation of the WAI-SF to measure the TA with the online program was carried out. An exploratory factor analysis was conducted in order to avoid determining the psychometric structure a priori, given the controversial structure of TA when technologies are involved (e.g., the structure was uni-dimensional in Miragall et al [ 25 ]; or bi-dimensional in Gómez-Penedo et al [ 24 ]). In addition, other potential variables influencing the TA with the online program were explored, as well as the capacity of the TA with the online program to predict therapeutic outcomes and satisfaction with the treatment.…”