The association between therapeutic alliance and outcome in internet-based psychological interventions: A meta-analysis

Efficacy of an internet-based guided trauma-focused intervention in reducing ICD-11 posttraumatic stress disorder symptoms: study protocol of a randomized controlled trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is a common mental disorder. However, many cases of PTSD remain untreated because of limited healthcare resources and other treatment-seeking barriers. Effective internet-based interventions could help to improve access to PTSD treatments. Therefore, the main objective of the planned randomized controlled trial is to evaluate the efficacy of the Lithuanian version of the guided internet-based self-help programme (Spring) in reducing ICD-11 PTSD symptoms.

METHODS

The planned sample size is 50 participants exposed to different traumatic experiences. Participants eligible for the study will be randomized into two study groups: the immediate treatment group and the delayed treatment control group. Both groups will receive guided trauma-focused ICBT intervention, but the delayed treatment group will receive access to the programme five months after randomization. The International Trauma Interview (ITI) will be used for the assessment of ICD-11 PTSD symptoms at pre-treatment, post-treatment, and at a 3-month follow-up. Changes in disturbances in self-organization, depression and anxiety levels, as well as posttraumatic cognitions and trauma-related shame, will also be evaluated. In addition, associations between changes in symptoms of PTSD and readiness for treatment, treatment expectations and working alliance will be explored. Changes in treatment outcomes will be evaluated using multiple Latent Change Models.

DISCUSSION

This study is expected to contribute to valuable knowledge on the efficacy of internet-based interventions for posttraumatic stress disorder.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06475716. Registered on 25 June 2024.

Internet-based therapist-supported interpersonal psychotherapy for depression: A randomized controlled trial

BACKGROUND

Depression is a common disorder for which there are several treatments options including different psychological treatments. The aim of this study was to investigate the effects of internet-based interpersonal psychotherapy (IPT) for symptoms of depression in randomized controlled trial.

METHODS

Following recruitment via advertisement a total of 113 participants with mild to moderate symptoms of depression were included and randomized to either a ten-week internet-based IPT with weekly therapist guidance or a waitlist control condition. The primary outcome was symptoms of depression measured weekly with the Montgomery Åsberg Depression Rating Scale (MADRS-S) and at pre- and post-treatment assessment with the Beck's Depression Inventory (BDI-II). Secondary outcomes were self-rated quality of life and symptoms of generalized anxiety disorder. We also measured therapeutic alliance and treatment credibility. Outcomes were evaluated with a latent growth curve model (for MADRS-S) and robust linear regression models (for the other measures). The trial was conducted during the Covid-19 pandemic in the spring of 2021.

RESULTS

Significant differences favoring the treatment group were found on three of the four outcomes: BDI-II, quality of life ratings, and ratings of generalized anxiety. Between-group effect sizes for these outcomes were moderate (BDI-II, quality of life) or small (generalized anxiety). The latent growth curve model did not indicate a significant difference on the weekly MADRS-S ratings. Exploratory analyses did not show an association between therapeutic alliance, treatment credibility and outcome.

LIMITATIONS

Missing data at post-treatment was high in the treatment group (37 %), though the missingness was not significantly related to observed ratings at pre-treatment or estimated trajectories during the treatment. Few participants completed all modules. The Covid-19 pandemic situation may have affected both effects and dropout rates.

CONCLUSIONS

Internet-based IPT can lead to significant improvements, though the reductions in symptoms of depression were not consistent across the two measures used. Completion rates and dropout patterns suggest a need for improved acceptability.

TRIAL REGISTRATION

The trial was preregistered at Clinicaltrials.gov (Identifier: NCT04721678). Registered January 2021.https://clinicaltrials.gov/study/NCT04721678.

Working alliance and its link to guidance in an internet-based intervention for depressive disorders: a secondary analysis of a randomized controlled trial

Background

Guided Internet-based interventions (IBIs) are typically found to be more effective than unguided ones, but the reasons behind this are not well understood. The therapist-client working alliance, crucial in face-to-face psychotherapy, is also increasingly recognized as an important factor in IBIs. This study examines trajectories of the working alliance and its relationship to therapeutic guidance through a secondary analysis of a randomized controlled trial (RCT) on Selfapy, a 12-week IBI based on cognitive behavioral therapy for depressive disorders. The trial compared a therapist-guided version (with weekly calls) to an unguided version (n = 301, mean age 37 years, 83% female, mean BDI-II = 30.09).

Methods

Based on an intention-to-treat approach, this study investigates within- and between-group differences in the quality of the working alliance, assessed with the WAI-SR questionnaire at mid- and post-treatment via repeated measures ANOVA. Furthermore, correlations and mediation analyses were conducted to explore the relationship between the working alliance and outcomes, as well as adherence parameters.

Results

Findings indicate that the IBI was successful in fostering a robust working alliance in both intervention groups, with similar ratings at mid-treatment but significantly higher ratings in the guided group at post-treatment (Cohen's d = -0.38). Post-treatment working alliance scores were positively linked to symptom reduction at post-treatment (guided: r = .25, unguided r = .15) and follow-up (guided: r = .25, unguided: r = .17). In the unguided group, the association was primarily driven by the subscale task. Serial mediation analysis indicated that the relationship between guidance and outcomes at follow-up was mediated by working alliance (b = 0.59; 95% CI: 0.14, 1.22) and a link between working alliance and adherence (b = 0.15; 95% CI: 0.04, 0.34).

Conclusions

Considering limitations like using a questionnaire developed for face-to-face therapy, findings support the importance of the working alliance in guided IBIs, while also providing new insights into its role and formation in unguided IBIs. The potential benefits of a strong working alliance, notably by improving adherence, may prove crucial for integrating guided as well as unguided IBIs into routine use, indicating the need for additional research in this context.

Clinical Trial Registration

https://tinyurl.com/2p9h5hnx, German Clinical Trials Register DRKS00017191.

PandaMom - Feasibility and acceptability of an internet- and mobile-based intervention to enhance peripartum mental well-being and to prevent postpartum depression

Background

Mental disorders during pregnancy and the postpartum period can have far-reaching consequences. To enhance peripartum mental well-being and prevent peripartum mental disorders, internet- and mobile-based interventions appear promising. They can overcome help-seeking barriers associated with face-to-face conditions and have proven to be effective. However, previous findings are scarce and mixed. The primary objectives of this study were to assess the feasibility and acceptability of an internet-based program aimed at enhancing peripartum mental well-being and preventing postpartum depression.

Methods

In total, 149 pregnant, German-speaking women were assigned to the internet-based intervention PandaMom. The program comprises a total of 10 basic and supplementary modules related to pregnancy and postpartum, based on cognitive-behavioral principles. Additionally, PandaMom offers professional, individualized guidance and a moderated group-chat. Assessments were conducted at baseline (pre-intervention), as well as two and five weeks postpartum. The primary outcomes included feasibility, user satisfaction, and adherence to the intervention. Secondary outcomes included depressive symptomatology, anxiety and stress.

Results

PandaMom was found to be feasible, and evaluation of module content and length satisfaction indicated that the intervention was well accepted. Nearly half of the participants utilized the guidance service by responding to individual messages from their intervention moderator. Regarding working alliance, participants reported a strong bond with their intervention moderator. Of the 149 participants, 132 logged into the platform at least once. 113 participants accessed at least one module, with an average of 4.7 modules opened per participant. However, only 16 participants completed the basic modules.

Conclusion

The findings of this study support previous evidence that internet-and mobile-based interventions are feasible and acceptable during pregnancy and the postpartum period. Further research is needed to address the challenge of low adherence and to evaluate the efficacy of PandaMom.

Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy

Background

The therapeutic alliance (TA) is a robust and pantheoretical predictor of treatment outcome in Face-to-Face- (F2F-) and Online-psychotherapy (Online-PT). Many authors have proposed several conceptualizations of TA, which are oftentimes operationalized. The resulting diversity of conceptualizations and measures is presented in this review.

Methods

We performed a three-parted literature search for self-report-instruments of TA in individual, voluntary F2F-PT with adults (1. utilization of past reviews, 2. systematic literature search yielding 5,205 articles, 3. reference lists). Analogously, we conducted a systematic literature search for instruments of TA in the Online-setting (yielding 200 articles). Additionally, we analyzed the content of the instruments qualitatively.

Results

A current overview of 48 instruments for measuring TA (46 for F2F-PT, 2 for Online-PT) including their conceptual backgrounds, characteristics and main content aspects is presented. Most instruments (n = 24) operationalize one or more theoretical conceptualizations of TA. Other instruments are adaptation/syntheses of existing measures (n = 14), based on literature searches (n = 3) or on an empirical survey (n = 3) and two instruments provide no conceptual background information. The content of the instruments mainly focused on the following aspects: 1. Self-disclosure and authenticity; 2. Agreement; 3. Active participation, motivation and compliance; 4. Trust and secure attachment; and 5. Considering needs/abilities/wishes of the patient. Additionally, a narrative review of various approaches to conceptualize TA is presented and linked to respective corresponding instruments.

Discussion

The broad variety of conceptualizations and measures of TA makes coherent research on TA difficult. There are conceptual challenges such as the role of attachment style in TA that remain to be clarified. The current conceptualizations and measures do not incorporate the practical experience and expertise of psychotherapists and patients sufficiently. A metatheoretical conceptualization and measure of TA based on an empirical survey of psychotherapists and patients could address these issues.

The association between quality of therapeutic alliance and treatment outcomes in teletherapy: A systematic review and meta-analysis

OBJECTIVE

The strength of the therapeutic alliance is widely understood to impact treatment outcomes, however, the alliance-outcome relationship in teletherapy has remained relatively unexamined. The aim of this meta-analysis is to systematically summarize the relationship between therapeutic alliance and treatment outcomes in teletherapy with adult patients conducted via videoconferencing or telephone.

METHODS

We conducted a systematic search of the databases PsycINFO, PsycARTICLES, ProQuest Dissertation Databases, EMBASE, The Cochrane Library, MEDLINE, Google Scholar, and PubMed for studies published before June 26, 2023. We identified 31 studies with 34 independent samples (4862 participants).

RESULTS

The average weighted effect size was 0.15, p = .001, 95% CI [0.07, 0.24], k = 34. reflecting a small effect of therapeutic alliance on mental health outcomes. There was significant heterogeneity in the effect sizes, which was driven by between-study differences in the alliance-outcome correlation. The alliance-outcome effect was larger when the alliance was measured late in treatment and when the outcome was measured from the patient's perspective.

CONCLUSION

Very few teletherapy treatment studies were identified that initially reported on alliance-outcome associations, underlining that this is an under-researched area. The association between alliance-teletherapy outcomes in this meta-analysis was small but significant, and somewhat weaker than the alliance-outcome associations reported for in-person treatments and other online interventions. This might indicate that there are other processes at play in teletherapy that explain variance of treatment outcomes, or that the therapist (and the relationship) has less influence on the treatment outcomes than in in-person therapy.

"Finding my voice again" - women's experiences of psychological therapy in perinatal secondary care settings: a qualitative study

Introduction

Although women often experience mental health comorbidities in the perinatal period, the evidence-base for psychological therapy across diagnostic boundaries in the perinatal period remains limited. As there is a need to understand experiences of therapy, irrespective of diagnosis, to inform intervention provision, the aims of this study were to explore women's experiences of psychological therapy for perinatal mental health difficulties and to identify the mechanisms that women attributed to the most significant therapeutic change for themselves and/or the mother-infant relationship.

Method

Semi-structured interviews were conducted with 16 women who received therapy within specialist perinatal community mental health settings in the Northwest of England, the UK. Interview data were analysed using reflexive thematic analysis.

Results

One overarching theme entitled participant life stories were at the heart of therapy was identified alongside three other main themes: 1.) We're in this together - therapeutic bond and establishing a coherent sense of self, 2.) Surfing the urge to 'fix' feelings - Sitting with emotions improved regulation and 3.) Seeing myself in a new light - Shifting self-blame to self-compassion enhanced self-efficacy. Theme 1 consisted of three subthemes. Participants described the quality of the therapeutic relationship as the fundamental foundation to (re)connecting with their needs, values and boundaries, which improved their sense of agency, self-esteem, therapeutic engagement and self-understanding. Shifting emotional avoidance to emotional engagement improved their self-regulation. Considering alternative factors that could have contributed to their experiences helped them to defuse self-blame and enhance self-compassion. Finally, changes in their mental health led to positive relational changes in their relationship with their infant and improved communication with partners.

Discussion

Sensitivity, engagement and responsivity experienced in the therapist-woman relationship was reported to be mirrored in the mother-infant relationship. Developing a coherent sense of self and self-regulation skills both appeared to heighten women's self-compassion and empathy for their infants, which also seemed to improve their ability to tolerate uncertainty and mixed emotions within themselves and their infants. The mechanisms of change in the perinatal period are important to consider at a stakeholder, therapist and service management level to parsimoniously and best meet the needs of women and the mother-infant relationship.

The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss

BACKGROUND

Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss.

METHODS

228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10).

RESULTS

Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms.

CONCLUSION

The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions.

TRIAL REGISTRATION

Not applicable.

Interpersonal factors in internet-based cognitive behavioral therapy for depression: Attachment style and alliance with the program and with the therapist

Objective This open-trial study examined effects of a culturally-adapted Hebrew version of guided internet-based cognitive behavioural therapy (ICBT) for depression. We examined therapeutic alliance with the therapist and with the programme (content) as potential predictors of outcomes. Furthermore, we examined whether anxious and avoidant attachment styles improved, although relationships were not the focus of treatment. Method: We examined alliance with therapist and alliance with programme and their time-lagged (1 week), longitudinal relationship with depression outcomes, and change in anxious and avoidant attachment during treatment. Results: Depression and insomnia improved significantly (Cohen's d: depression = 1.34, insomnia = 0.86), though dropout was relatively high (49%). Alliance with programme and with the therapist predicted adherence and dropout, whereas only alliance with therapist predicted symptom improvement. Avoidant attachment decreased over treatment whereas anxious attachment did not. Conclusion: A culturally-adapted version of ICBT for depression showed that alliance with therapist and alliance with programme both can play an important role in its effectiveness: alliance with programme and the therapist drive adherence and dropout and alliance with therapist is related to symptom improvement. Although the focus of treatment is not interpersonal, avoidant attachment style can improve following ICBT.

Development and validation of an 8-item version of the Real Relationship Inventory-Client form

OBJECTIVE

To develop and validate a very brief version of the 24-item Real Relationship Inventory-Client (RRI-C) form.

METHOD

Two independent samples of individual psychotherapy patients (Nsample1 = 700, Nsample2 = 434) completed the RRI-C along with other measures. Psychometric scale shortening involved exploratory factor analysis, item response theory analysis, confirmatory factor analysis (CFA), and multigroup CFA. Reliability and convergent and discriminant validity of the scale and subscales were also assessed.

RESULTS

The 8-item RRI-C (RRI-C-SF) preserves the two-factor structure: Genuineness (k = 4, α = .86) and Realism (k = 4, α = .87), which were correlated at r = .74. CFA provided the following fit indices for the bifactor model: X2/df = 2.16, CFI = .99, TLI = .96, RMSEA = .07, and SRMR = .03. Multigroup CFA showed that the RRI-C-SF was invariant across in-person and remote session formats. The RRI-C-SF demonstrated high reliability (α = .91); high correlation with the full-length scale (r = .96); and excellent convergent and discriminant validity with measures of other elements of the therapeutic relationship, personality characteristics, current mental health state, and demographic-clinical variables. Clinical change benchmarks were calculated to serve as valuable tools for both research and clinical practice.

CONCLUSION

The RRI-C-SF is a reliable measure that can be used for both research and clinical purposes. It enables a nuanced assessment of the genuineness and the realism dimensions of the real relationship.

Predictors and moderators of outcome of ICBT for loneliness with guidance or automated messages - A secondary analysis of a randomized controlled trial

Internet-based cognitive behavioral therapy (ICBT) is promising in alleviating loneliness in adults. Identifying individuals who benefit from ICBT for loneliness is pivotal to offering this intervention in a more targeted way and improving the intervention for those who do not benefit. This secondary analysis of a randomized controlled trial (RCT) aimed to identify predictors and moderators of outcome of an ICBT with guidance or automated messages for loneliness. In the RCT, 243 participants suffering from loneliness were randomly assigned to an ICBT with guidance (n = 98), automated messages (n = 97), or a waitlist-control condition (n = 48). In total, 180 participants completed the post-assessment (i.e., 10 weeks post-randomization). Outcomes were treatment outcome assessed with the UCLA-9 Loneliness Scale at post-assessment and treatment response, i.e., reliable improvement on the UCLA-9 from pre- to post. The relationship between a wide range of patient characteristics (grouped into socio-demographic, clinical, loneliness-specific, and treatment-related variables) and outcome was analyzed using multiple linear and logistic regressions. Feeling less burdened by loneliness resulted in higher odds of reliable improvement in guided ICBT compared to the waitlist-control condition. No treatment outcome or response moderators were identified for ICBT with automated messages compared to the waitlist-control group. Across active intervention groups, loneliness at baseline, age and fit between the tasks and goals of the intervention and participants' need predicted treatment outcome. Predictors of treatment response for ICBT with guidance and automated messages were not identified, and no variables differentially predicted the effects of ICBT with guidance or automated messages on the outcomes. In conclusion, individuals less burdened by their feelings of loneliness benefited more from guided ICBT. Lower baseline loneliness scores, younger age, and a better match between tasks and goals of the intervention and participants' needs also predicted a more favorable treatment outcome for both ICBT with guidance and automated messages.

Experiences of telehealth among people receiving alcohol and other drug treatment during the COVID-19 pandemic: Implications for future telehealth delivery

INTRODUCTION

The novel coronavirus (COVID-19) pandemic necessitated the rapid uptake of telehealth to deliver treatment for alcohol and other drug (AOD) concerns. However, little is known about how the move from in-person to telehealth delivery impacted clients' experience of care. This qualitative study aimed to explore experiences of telehealth among people receiving alcohol and other drug treatment during the COVID-19 pandemic, and their preferences regarding future telehealth care.

METHODS

Participants were aged 34-66 years (M = 44 years, 60% male) and were recruited from Victorian AOD treatment services and consumer networks. A total of 20 semi-structured interviews were analysed using thematic analysis.

RESULTS

Three themes were identified: (i) experiences of the practical impacts of telehealth; (ii) experiences of telehealth interactions; and (iii) preferences for future telehealth. Contextual factors, including location and socioeconomic status, were found to impact clients' ability to access reliable telehealth with sufficient privacy. While telehealth was generally associated with increased treatment engagement (for a typically stigmatised population), participants noted varying effects on the therapeutic alliance. Although in-person treatment was generally favoured, participants often valued telehealth as a modality to provide empathic care during the pandemic. Participants expressed a preference for a hybrid treatment model in the future, in which they could choose a combination of telehealth and in-person services.

CONCLUSION

Client and clinician information and training are vital to improve the future delivery of telehealth for AOD treatment.

Web-based guided self-help cognitive behavioral therapy-enhanced versus treatment as usual for binge-eating disorder: a randomized controlled trial protocol

Binge-eating disorder (BED) is a psychiatric disorder characterized by recurrent episodes of eating a large amount of food in a discrete period of time while experiencing a loss of control. Cognitive behavioral therapy-enhanced (CBT-E) is a recommended treatment for binge-eating disorder and is typically offered through 20 sessions. Although binge-eating disorder is highly responsive to CBT-E, the cost of treating these patients is high. Therefore, it is crucial to evaluate the efficacy of low-intensity and low-cost treatments for binge-eating disorder that can be offered as a first line of treatment and be widely disseminated. The proposed noninferiority randomized controlled trial aims to determine the efficacy of web-based guided self-help CBT-E compared to treatment-as-usual CBT-E. Guided self-help will be based on a self-help program to stop binge eating, will be shorter in duration and lower intensity, and will require fewer therapist hours. Patients with binge-eating disorder (N = 180) will be randomly assigned to receive guided self-help or treatment-as-usual. Assessments will take place at baseline, mid-treatment, at the end of treatment, and at 20- and 40-weeks post-treatment. Treatment efficacy will be measured by examining the reduction in binge-eating days in the previous 28 days between baseline and the end of treatment between groups, with a noninferiority margin (Δ) of 1 binge-eating day. Secondary outcomes will include full remission, body shape dissatisfaction, therapeutic alliance, clinical impairment, health-related quality of life, attrition, and an economic evaluation to assess cost-effectiveness and cost-utility. The moderators examined will be baseline scores, demographic variables, and body mass index. It is expected that guided self-help is noninferior in efficacy compared to treatment-as-usual. The proposed study will be the first to directly compare the efficacy and economically evaluate a low-intensity and low-cost binge-eating disorder treatment compared to treatment-as-usual. If guided self-help is noninferior to treatment-as-usual in efficacy, it can be widely disseminated and used as a first line of treatment for patients with binge-eating disorder. The Dutch trial register number is R21.016. The study has been approved by the Medical Research Ethics Committees United on May 25th, 2021, case number NL76368.100.21.

The Association Between Emotion Recognition and Internalizing Problems in Children and Adolescents: A Three-Level Meta-Analysis

Numerous studies have explored the link between how well youth recognize emotions and their internalizing problems, but a consensus remains elusive. This study used a three-level meta-analysis model to quantitatively synthesize the findings of existing studies to assess the relationship. A moderation analysis was also conducted to explore the sources of research heterogeneity. Through a systematic literature search, a total of 42 studies with 201 effect sizes were retrieved for the current meta-analysis, and 7579 participants were included. Emotion recognition was negatively correlated with internalizing problems. Children and adolescents with weaker emotion recognition skills were more likely to have internalizing problems. In addition, this meta-analysis found that publication year had a significant moderating effect. The correlation between emotion recognition and internalizing problems decreased over time. The degree of internalizing problems was also found to be a significant moderator. The correlation between emotion recognition and internalizing disorders was higher than the correlation between emotion recognition and internalizing symptoms. Deficits in emotion recognition might be relevant for the development and/or maintenance of internalizing problems in children and adolescents. The overall effect was small and future research should explore the clinical relevance of the association.

Effects of general change mechanisms on outcome in telephone-based cognitive-behavioral therapy for distressed family caregivers

BACKGROUND

The study investigated the influence of general change mechanisms (GCMs) on outcome in telephone-based cognitive-behavioral therapy (CBT) for family caregivers.

METHODS

In a stepped-care intervention approach, highly distressed family caregivers received telephone-based CBT after completing a care counseling intervention. Sixty-six therapist-caregiver dyads rated emotional bond, agreement on collaboration, problem actuation, resource activation, clarification of meaning, and mastery after each of 12 therapy sessions. Outcomes were caregiver burden (SCQ-AV) and depression (CES-D) after therapy. Associations of GCMs with outcome were examined in multilevel regression models.

RESULTS

Caregiver burden was significantly predicted by caregiver-rated emotional bond (β = -0.18) as well as therapist-rated resource activation (β = -0.26), problem actuation (β = -0.22), clarification of meaning (β = -0.18), and mastery (β = -0.18). None of the GCMs predicted depression from any perspective.

CONCLUSION

The findings suggest that GCMs are relevant for reducing caregiver burden in CBT for family caregivers and should be fostered in treatment manuals, in particular therapist-rated GCMs. Since therapist and caregiver perspectives differed in predicting caregiver burden, future research should investigate perspective congruence and its effect on therapy outcome.

StudiCare procrastination - Randomized controlled non-inferiority trial of a persuasive design-optimized internet- and mobile-based intervention with digital coach targeting procrastination in college students

BACKGROUND

Academic procrastination is widespread among college students. Procrastination is strongly negatively correlated with psychological well-being, thus early interventions are needed. Internet- and mobile-based cognitive behavioral therapy (iCBT) could provide a low-threshold treatment option. Human guidance seems to be a decisive mechanism of change in iCBT. Persuasive design optimization of iCBT and guidance by a digital coach might represent a resource-saving alternative. The study evaluated the non-inferiority of a digital coach in comparison to human guidance with regard to the primary outcome procrastination.

METHODS

The iCBT StudiCare procrastination was optimized by principles of the Persuasive System Design (PSD). A total of 233 college students were randomly assigned to either StudiCare procrastination guided by a digital coach (intervention group, IG) or by a human eCoach (control group, CG). All participants were assessed at baseline, 4-, 8- and 12-weeks post-randomization. Symptom change and between-group differences were assessed with latent growth curve models and supported by effect size levels. The non-inferiority margin was set at Cohen's d = - 0.3.

RESULTS

The primary outcome procrastination measured by the Irrational Procrastination scale (IPS) significantly decreased across groups (γ = - 0.79, p < .001, Cohen's d = -0.43 to -0.89) from baseline to 12-weeks post-randomization. There were no significant differences between groups (γ = -0.03, p = .84, Cohen's d = -0.03 to 0.08). Regarding symptoms of depression, no significant time x group effect was found (γ = 0.26, p = .09; Cohen's d = -0.15 to 0.21). There was also no significant time x group effect on the improvement of symptoms of anxiety (γ = 0.25, p = .09). However, Cohen's ds were above the non-inferiority margin 8-weeks (Cohen's d = 0.51) and 12-weeks post-randomization (Cohen's d = 0.37), preferring the CG. Of the IG, 34% and of the CG, 36% completed 80% of the modules.

CONCLUSIONS

The PSD optimized version of StudiCare procrastination is effective in reducing procrastination. The digital coach was not inferior to human guidance. Guidance by a digital coach in iCBT against procrastination for college students could be a resource-saving alternative to human guidance.

TRIAL REGISTRATION

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trial Register (ID: DRKS00025209, 30/04/2021).

The role of therapist support on the efficacy of an internet-delivered stress recovery intervention for healthcare workers: a randomized control trial

Internet-delivered CBT interventions effectively improve different aspects of mental health, although the therapist's role remains unclear. The aim of this trial was to evaluate the efficacy of a therapist-supported 6-week internet-delivered intervention in improving stress recovery among healthcare workers compared to a group with optional therapist support. A total of 196 participants were recruited and randomly allocated to regular therapists' support or optional therapists' support groups. The primary outcome measure was the Recovery Experiences Questionnaire (REQ), developed to assess four components of stress recovery: psychological detachment, relaxation, mastery, and control. Secondary outcomes measured perceived stress (PSS-10), anxiety (GAD-7), depression (PHQ-9), and psychological well-being (WHO-5). All four stress recovery skills improved significantly after participating in the intervention at a 3-month follow-up, with small to medium effects (0.27-0.65) in both groups. At follow-up, we also found a significant reduction in perceived stress, depression, and anxiety in both groups, as well as an improvement in psychological well-being. The results indicate that ICBT can be effective in improving stress recovery skills among healthcare workers with optional support from the therapist, provided at the participants' request. This RCT suggests that optional therapist support could meet participants' needs and reduce resources needed in routine care.

Who benefits from guided internet-based interventions? A systematic review of predictors and moderators of treatment outcome

To our knowledge, no systematic review has been conducted on predictors or moderators of treatment outcome across diagnoses in guided internet-based interventions (IBIs) for adults. To identify who benefits from this specific format and therein inform future research on improving patient-treatment fit, we aimed to aggregate results of relevant studies. 2100 articles, identified by searching the databases PsycInfo, Ovid Medline, and Pubmed and through snowballing, were screened in April/May 2021 and October 2022. Risk of bias and intra- and interrater reliability were assessed. Variables were grouped by predictor category, then synthesized using vote counting based on direction of effect. N = 60 articles were included in the review. Grouping resulted in 88 predictors/moderators, of which adherence, baseline symptoms, education, age, and gender were most frequently assessed. Better adherence, treatment credibility, and working alliance emerged as conclusive predictors/moderators for better outcome, whereas higher baseline scores predicted more reliable change but higher post-treatment symptoms. Results of all other predictors/moderators were inconclusive or lacked data. Our review highlights that it is currently difficult to predict, across diagnoses, who will benefit from guided IBIs. Further rigorous research is needed to identify predictors and moderators based on a sufficient number of studies. PROSPERO registration: CRD42021242305.

Relationship Factors in Internet-Delivered Psychological Interventions for Veterans Experiencing Postpartum Depression: Qualitative Analysis

BACKGROUND

Internet-delivered psychological interventions (IPIs) have been shown to be effective for a variety of psychological concerns, including postpartum depression. Human-supported programs produce better adherence and larger effect sizes than unsupported programs; however, what it is about support that affects outcomes is not well understood. Therapeutic alliance is one possibility that has been found to contribute to outcomes; however, the specific mechanism is not well understood. Participant perspectives and qualitative methodology are nearly absent from the IPI alliance research and may help provide new directions.

OBJECTIVE

In this study, we aimed to provide participant perspectives on engagement with an IPI for postpartum depression to help inform alliance research, development of new IPIs, and inform resource allocation.

METHODS

A qualitative methodology was used to explore participant perspectives of veteran women's engagement with the MomMoodBooster program, a human-supported internet-delivered intervention for postpartum depression. Participants were asked 4 open-ended questions with the 3-month postintervention survey, "In what ways did you find the MomMoodBooster most helpful?" "How do you think the MomMoodBooster could have been improved?" "In what ways did you find the personal coach calls to be helpful?" and "How do you think the personal coach calls could have been improved?"

RESULTS

Data were collected from 184 participants who responded to at least 1 of the open-ended questions. These were analyzed using thematic analysis and a process of reaching a consensus among coders. The results suggest that not only the engagement with the support person is perceived as a significant contributor to participant experiences while using the MomMoodBooster content but also the relationship factors are particularly meaningful. The results provide insights into the specific qualities of the support person that were perceived as most impactful, such as warmth, empathy and genuineness, and feeling normalized and supported. In addition, the results provide insight into the specific change processes that can be targeted through support interactions, such as encouraging self-reflection and self-care and challenging negative thinking.

CONCLUSIONS

These data emphasize the importance of relationship factors between support persons and an IPI program for postpartum depression. The findings suggest that focusing on specific aspects of the alliance and the therapeutic relationship could yield fruitful directions for the training of support personnel and for future alliance-based research of internet-delivered treatments.

Factors Affecting Digital Tool Use in Client Interaction According to Mental Health Professionals: Interview Study

BACKGROUND

Digital tools and interventions are being increasingly developed in response to the growing mental health crisis, and mental health professionals (MHPs) considerably influence their adoption in client practice. However, how MHPs use digital tools in client interaction is yet to be sufficiently understood, which poses challenges to their design, development, and implementation.

OBJECTIVE

This study aimed to create a contextual understanding of how MHPs use different digital tools in clinical client practice and what characterizes the use across tools.

METHODS

A total of 19 Finnish MHPs participated in semistructured interviews, and the data were transcribed, coded, and inductively analyzed.

RESULTS

We found that MHP digital tool use was characterized by 3 distinct functions: communication, diagnosis and evaluation, and facilitating therapeutic change. The functions were addressed using analog tools, digitized tools that mimic their analog counterparts, and digital tools that use the possibilities native to digital. The MHP-client communication included various media alongside face-to-face meetings, the MHPs increasingly used digitized tools in client evaluation, and the MHPs actively used digitized materials to facilitate therapeutic change. MHP tool use was generally characterized by adaptability-it was negotiated in client interactions. However, there was considerable variance in the breadth of MHPs' digital toolbox. The existing clinical practices emphasized MHP-client interaction and invited incremental rather than radical developments, which challenged the achievement of the scalability benefits expected from digital tools.

CONCLUSIONS

MHPs use digitized and digital tools in client practice. Our results contribute to the user-centered research, development, and implementation of new digital solutions in mental health care by classifying them according to their function and medium and describing how MHPs use and do not use them.

Online Training Process Groups for Therapists: A Proposed Model

The article proposes a new model for online experiential training groups for therapists. Experiential groups are an essential part of training for group therapists. The article summarizes the requirements for becoming a group therapist, reviews the literature about training-process groups for therapists, and discusses the dilemmas that are part of these groups. Ethical questions and the difference between training-process groups and therapy groups are presented. This training model uses weekly online process group sessions that include a 10-minute didactic discussion at the end of each session, combined with an annual in-person intensive meeting. Group vignettes are included to illustrate group processes. The advantages and disadvantages of the model are discussed, as well as important areas for future research.

Working alliance in low-intensity internet-based cognitive behavioral therapy for depression in primary care in Spain: A qualitative study

Introduction

Psychotherapies delivered via the Internet have been promoted as an alternative for improving access to psychological treatments. A conceptual working alliance model of blended (i.e., traditional face-to-face consultation combined with Internet-delivered psychotherapy) cognitive-behavioral therapy (b-CBT) for depression has been developed in the UK. However, little is known about how this important therapeutic process, namely the working alliance (WA), is developed and maintained in Internet-delivered cognitive-behavioral therapy without face-to-face consultation (i-CBT). The aim of this study was to evaluate the validity of the WA model of b-CBT in Spanish patients with depression receiving i-CBT.

Methods

Forty-one patients suffering from mild-moderate depression were interviewed to assess their experiences of an i-CBT program. Interviews were conducted with participants who received a self-guided application (n = 9), and low-intensity support (n = 10). Three group interviews were also conducted with patients who either did not start the program (n = 8) or did not complete it (n = 6), and with patients who did complete it (n = 8).

Results

Qualitative thematic content analysis was performed using the constant comparative method, which revealed four main themes: "bond," "goals," "task," and "usability heuristics," all consistent with the existing literature. However, a new subcategory emerged, called "anonymity," which may highlight the social stigma that mental illness still has in the Spanish context.

Conclusion

Results suggest that the development and maintenance of the WA through i-CBT could offer a better experience of the therapeutic process and improve the clinical impact.

Clinical Trial Registration

Clinicaltrials.gov, identifier: NCT01611818.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Factors Associated With Treatment Response in an Internet-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement

Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.

Working alliance and adherence mediate the effect of guidance in a web-based program for participants with mild to moderate depressive symptoms: A secondary mediation analysis

Guided web-based self-help programs for individuals with depressive symptoms have shown to be more efficacious than unguided programs. However, research has paid little attention to why guided interventions are superior. The present study investigated whether working alliance and adherence to the program mediated the effect of guidance on depressive symptom outcome. The study is a secondary analysis of a randomized factorial trial. In the trial, 302 adults with mild to moderate depressive symptoms (Patient Health Questionnaire-9 score: 5-14) were randomized to either a guided or an unguided group. All participants received access to a web-based self-help program based on problem-solving therapy. Working alliance with the treatment providers was assessed using an adapted version of the Working Alliance Inventory for Guided Internet Interventions two weeks (early-treatment) and eight weeks (post-treatment) after pre-treatment. The primary outcome was depressive symptoms at post-treatment. The total working alliance score was significantly higher for guided participants compared to unguided participants (at early-treatment: t _248.6 = -3.36, p < .001, d = 0.42, at post-treatment: t _194.9 = -4.77, p < .001, d = 0.66). The total working alliance score correlated significantly with the change in depressive symptoms for guided (rs = 0.16, 0.34) and unguided participants (rs = 0.26, 0.23). The WAI-I total score statistically mediated the relationship between guidance and outcome (at early-treatment: B = -0.028, at post-treatment: B = -0.053). Furthermore, the subscale tasks (at post-treatment: B = -0.051), the subscale goals (at early-treatment: B = -0.031 and at post-treatment: B = -0.052), and adherence to the program (B = -0.034) mediated the relationship between guidance and outcome. Finally, in a multiple mediation model both early-treatment working alliance and adherence to the program (B = -0.050) mediated the relationship between guidance and outcome. These findings indicate that guidance increases working alliance to treatment providers as early as two weeks after treatment beginning. The alliance predicts outcome and mediates the relationship between guidance and outcome. Participants' agreement with tasks and goals of a program seems to be more important than the bond with treatment providers. Treatment providers might therefore attune web-based programs to the preferences and expectations of participants. In addition to the working alliance, adherence to the program co-mediates the relationship between guidance and outcome.

Synthesis of the Evidence on What Works for Whom in Telemental Health: Rapid Realist Review

BACKGROUND

Telemental health (delivering mental health care via video calls, telephone calls, or SMS text messages) is becoming increasingly widespread. Telemental health appears to be useful and effective in providing care to some service users in some settings, especially during an emergency restricting face-to-face contact, such as the COVID-19 pandemic. However, important limitations have been reported, and telemental health implementation risks the reinforcement of pre-existing inequalities in service provision. If it is to be widely incorporated into routine care, a clear understanding is needed of when and for whom it is an acceptable and effective approach and when face-to-face care is needed.

OBJECTIVE

This rapid realist review aims to develop a theory about which telemental health approaches work (or do not work), for whom, in which contexts, and through what mechanisms.

METHODS

Rapid realist reviewing involves synthesizing relevant evidence and stakeholder expertise to allow timely development of context-mechanism-outcome (CMO) configurations in areas where evidence is urgently needed to inform policy and practice. The CMO configurations encapsulate theories about what works for whom and by what mechanisms. Sources included eligible papers from 2 previous systematic reviews conducted by our team on telemental health; an updated search using the strategy from these reviews; a call for relevant evidence, including "gray literature," to the public and key experts; and website searches of relevant voluntary and statutory organizations. CMO configurations formulated from these sources were iteratively refined, including through discussions with an expert reference group, including researchers with relevant lived experience and frontline clinicians, and consultation with experts focused on three priority groups: children and young people, users of inpatient and crisis care services, and digitally excluded groups.

RESULTS

A total of 108 scientific and gray literature sources were included. From our initial CMO configurations, we derived 30 overarching CMO configurations within four domains: connecting effectively; flexibility and personalization; safety, privacy, and confidentiality; and therapeutic quality and relationship. Reports and stakeholder input emphasized the importance of personal choice, privacy and safety, and therapeutic relationships in telemental health care. The review also identified particular service users likely to be disadvantaged by telemental health implementation and a need to ensure that face-to-face care of equivalent timeliness remains available. Mechanisms underlying the successful and unsuccessful application of telemental health are discussed.

CONCLUSIONS

Service user choice, privacy and safety, the ability to connect effectively, and fostering strong therapeutic relationships need to be prioritized in delivering telemental health care. Guidelines and strategies coproduced with service users and frontline staff are needed to optimize telemental health implementation in real-world settings.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO); CRD42021260910; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021260910.

Technological Advances in Cognitive-Behavioral Therapy and Clinical Practice: Challenges in an Evolving Field

Technological innovations in cognitive-behavioral therapy (CBT) provide excellent opportunities for mental health clinicians to expand access to mental health treatment among culturally diverse and marginalized populations. This brief report highlights challenges that mental health clinicians encounter as they integrate technological innovations in CBT into their work with diverse clients and provides recommendations for addressing them. The authors identify five key challenges of using technology-driven CBT: development of the therapeutic alliance; potential fit for clients from culturally diverse backgrounds and marginalized groups; geographic and economic access; ethical and legal concerns; and competency in CBT practice, training, and supervision. Technological advances in CBT allow clinicians to treat more individuals from underserved communities. Existing challenges compel clinicians across disciplines to ensure that their practice is congruent with CBT practice values and ethics, policy, and research and that the best available CBT intervention can be integrated into all aspects of mental health practice.

Attitudes toward innovative mental health treatment approaches in Germany: E-mental health and home treatment

E-mental health and home treatment are treatment approaches that have proven to be effective, but are only slowly implemented in the German health care system. This paper explores the attitudes toward these innovative treatment approaches. Data was collected in two large, non-clinical samples representative of the German population in spring 2020 (N = 2,503) and winter 2020/2021 (N = 2,519). Statistical associations between variables were examined using two-tailed tests. Binary and multinomial logistic regressions were performed to predict attitudes toward online-based treatment concepts and home treatment approaches. Only few (<20%) people preferred online-based treatment approaches, while a larger proportion (~50%) could imagine being treated at home. Overall, younger subjects were more open to online-therapy approaches, while people with lower education preferred more often a traditional therapy setting. Acceptance of online-therapy did not raise significantly during the first months of the COVID-19 pandemic. When different online-based treatment options were available, the probability of accepting home treatment significantly increased with increasing levels of therapeutic support. Further promotion of acceptance for online-therapy and home treatment seems to be necessary. In the future, more information on innovative treatment approaches should be actively provided.

Conceptual Invariance, Trajectories, and Outcome Associations of Working Alliance in Unguided and Guided Internet-Based Psychological Interventions: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

The role of working alliance remains unclear for many forms of internet-based interventions (IBIs), a set of effective psychotherapy alternatives that do not require synchronous interactions between patients and therapists.

OBJECTIVE

This study examined the conceptual invariance, trajectories, and outcome associations of working alliance across an unguided IBI and guided IBIs that incorporated clinician support through asynchronous text messaging or video messaging.

METHODS

Adults with high education attainment (n=145) with subclinical levels of anxiety, stress, or depressive symptoms were randomized to 1 of 3 treatment conditions for 7 weeks. All participants received treatments from MyCompass, an unguided IBI using cognitive behavior therapy. Participants in condition 2 and 3 received supplemental, asynchronous clinician support through text and video, respectively. Working alliance with the IBIs was measured weekly using select items from the 12-item version of the Agnew Relationship Measure. Symptom and functional outcomes were assessed at baseline, at the end of treatment, and 1-month follow-up.

RESULTS

Working alliance with the IBIs was conceptually invariant across the 3 conditions. Working alliance followed a quadratic pattern of change over time for all conditions and declined significantly only in the text-support condition. After controlling for baseline symptoms, higher baseline levels of working alliance predicted less depression and less functional impairment at follow-up, whereas faster increases in working alliance predicted less worry at the end of treatment and at follow-up, all of which only occurred in the video-support condition.

CONCLUSIONS

Working alliance with the IBIs was generally established in the initial sessions. Although working alliance is conceptually invariant across IBIs with or without clinician support, the associations between working alliance and treatment outcomes among IBIs may differ depending on clinician involvement and the modalities of support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05122429; https://clinicaltrials.gov/ct2/show/NCT05122429.

Therapeutic Alliance in Online and Face-to-face Psychological Treatment: Comparative Study

BACKGROUND

Since the COVID-19 pandemic, the number of online mental health treatments have grown exponentially. Additionally, it seems inevitable that this technical resource is here to stay at health centers. However, there is still very little scholarly literature published on this topic, and therefore, the impact of the changes that have had to be dealt with in this regard has not been studied.

OBJECTIVE

This study aims to evaluate the differences in the establishment of the therapeutic alliance (TA) based on the intervention modality (online or face-to-face), the type of attachment, and diagnosis.

METHODS

A total of 291 subjects participated in the study, 149 (51.2%) of whom were men and 142 were (48.8%) women between the ages of 18 and 30 years. The instruments used were sociodemographic data, SOFTA-o (System for Observing Family Therapeutic Alliances-observational), and Relationship Questionnaire.

RESULTS

The results show that the treatments conducted face-to-face obtain significantly better scores in the creation of the TA than those conducted online (t=-42.045, df=289, P<.001). The same holds true with attachment, in that users with secure attachment show a better TA than those with insecure attachment (t=6.068, P<.001,), although there were no significant differences with the diagnosis (F=4.566, P=.44), age (r=0.02, P=.70), and sex (t=0.217, P=.33).

CONCLUSIONS

We believe that professionals are not yet prepared to conduct remote treatment with a degree of efficacy similar to that of face-to-face. It is essential for professionals to receive training in this new technical resource and to understand and incorporate the variants it entails into their daily practice.

Perceptions of Telemental Health Care Delivery During COVID-19: A Cross-Sectional Study With Providers, February-March 2021

The COVID-19 pandemic accelerated adoption of telemental health (TMH). Providers with limited TMH experience faced challenges during the rapid switch to remote patient care. We investigated TMH providers' perceptions about remote care one year into the pandemic according to when providers adopted telemedicine (i.e., before vs. after March 2020) and how much of their caseloads were served remotely (i.e., < 50% vs. ≥ 50%). Between February-March 2021, 472 TMH providers completed a cross-sectional, web-based survey that measured perceived benefits and satisfaction with telemedicine, therapeutic alliance, patient-centered communication, eHealth literacy, multicultural counseling self-efficacy, and facilitating factors of using telemedicine. Providers who began using telemedicine before the pandemic reported having better training, task-related therapeutic alliance with patients, and ability to conduct multicultural interventions, assessments, and session management. Providers who served ≥ 50% of their caseload remotely reported greater satisfaction with their practice, stronger beliefs about the benefits of telemedicine, and greater perceived effects of telemedicine on alleviating the impact of COVID-19. There were no differences in reports of patient-centered communication nor eHealth literacy. In conclusion, providers who adopted TMH more recently may require additional training and support to successfully establish a working alliance with their patients, especially with multicultural aspects of care.

Eliciting emotional expressions in psychodynamic psychotherapies using telehealth: a clinical review and single case study using emotional awareness and expression therapy

The COVID-19 pandemic and ensuing social distancing requirements resulted in an abrupt transition in the provision of most mental healthcare to telehealth; yet it was, at first, unclear whether patients' emotional expressions - of great import to the success of many psychodynamic therapies - could be facilitated using teletherapy. This article first presents a targeted literature review focused on emotional expressions in psychotherapy and implementing psychodynamic therapy over telehealth and then describes our clinical experience transitioning a psychodynamically-informed, evidence-based, and experiential group treatment for chronic pain, emotional awareness and expression therapy (EAET), to video telehealth at VA Greater Los Angeles Healthcare System. We discuss barriers we encountered in our implementation of EAET over video telehealth but also illustrate the ultimate success of the approach using verbatim excerpts from our therapeutic work, which aim to demonstrate the potential to facilitate powerful emotional expressions over video telehealth when conducting a psychodynamically-informed treatment. We examine the possible applications for video telehealth to maintain emotionally focused, psychodynamic psychotherapy administration and enhance its teaching and training. Although we describe limitations of our specific approach, ultimately, our experience supports the potential efficacy of experiential, emotion-focused psychodynamic therapies in a telehealth setting.

Using AI chatbots to provide self-help depression interventions for university students: A randomized trial of effectiveness

BACKGROUND

Depression impacts the lives of a large number of university students. Mobile-based therapy chatbots are increasingly being used to help young adults who suffer from depression. However, previous trials have short follow-up periods. Evidence of effectiveness in pragmatic conditions are still in lack.

OBJECTIVE

This study aimed to compare chatbot therapy to bibliotherapy, which is a widely accepted and proven-useful self-help psychological intervention. The main objective of this study is to add to the evidence of effectiveness for chatbot therapy as a convenient, affordable, interactive self-help intervention for depression.

METHODS

An unblinded randomized controlled trial with 83 university students was conducted. The participants were randomly assigned to either a chatbot test group (n = 41) to receive a newly developed chatbot-delivered intervention, or a bibliotherapy control group (n = 42) to receive a minimal level of bibliotherapy. A set of questionnaires was implemented as measurements of clinical variables at baseline and every 4 weeks for a period of 16 weeks, which included the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder scale (GAD-7), the Positive and Negative Affect Scale (PANAS). The Client Satisfaction Questionnaire-8 (CSQ-8) and the Working Alliance Inventory-Short Revised (WAI-SR) were used to measure satisfaction and therapeutic alliance after the intervention. Participants' self-reported adherence and feedback on the therapy chatbot were also collected.

RESULTS

Participants were all university students (undergraduate students (n = 31), postgraduate students (n = 52)). They were between 19 and 28 years old (mean = 23.08, standard deviation (SD) = 1.76) and 55.42% (46/83) female. 24.07% (20/83) participants were lost to follow-up. No significant group difference was found at baseline. In the intention-to-treat analysis, individuals in the chatbot test group showed a significant reduction in the PHQ-9 scores (F = 22.89; P < 0.01) and the GAD-7 scores (F = 5.37; P = 0.02). Follow-up analysis of completers suggested that the reduction of anxiety was significant only in the first 4 weeks. The WAI-SR scores in the chatbot group were higher compared to the bibliotherapy group (t = 7.29; P < 0.01). User feedback showed that process factors were more influential than the content factors.

CONCLUSIONS

The chatbot-delivered self-help depression intervention was proven to be superior to the minimal level of bibliotherapy in terms of reduction on depression, anxiety, and therapeutic alliance achieved with participants.

Benefits of Digital Mental Health Care Interventions for Correctional Workers and Other Public Safety Personnel: A Narrative Review

Chronic exposure to stressors and potentially psychologically traumatic events contributes to the high prevalence of mental health disorders in correctional workers (CWs) and other public safety personnel (PSP). Digital mental health interventions are an accessible and scalable method of improving and maintaining the mental health of this population. The current review explores the benefits of digital mental health interventions for PSP-with a focus on CWs-and how these innovations can address the limitations in in-person mental health care. A systematic literature search of five databases (Medline, PsycInfo, Embase, CINAHL, Google Scholar) was conducted until March 2022. The search yielded 16 publications that focused on digital mental health interventions or care available to CWs and other PSP. The benefits of digital innovations were summarized into five categories which discussed (1) their ability to enhance accessibility and reduce stigma; (2) the provision of evidence-based and structured psychotherapy programs; (3) variability in the degree of therapist engagement; (4) the integration of proactive interventions; and (5) enhancing engagement by acknowledging unique experiences and interpersonal relationships. Although digital mental health technologies for CWs are still in their infancy, there is strong evidence to support their effectiveness in ameliorating symptoms of mental distress. Future research should consider how ethnicity, gender, culture, sexual orientation, and socioeconomic status can be integrated into these therapies and how the interplay between different stakeholders and organizations can impact the effectiveness of online therapies and programs.

Responsible Relations: A Systematic Scoping Review of the Therapeutic Alliance in Text-Based Digital Psychotherapy

Introduction: Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy. Text-based digital psychotherapy has become increasingly common, yet much remains unclear about the alliance and its importance for delivering mental health care via a digital format. To employ text-based digital therapies responsibly, more insight is needed into the type and strength of the therapeutic alliance online. Methods: A systematic scoping review was performed searching four databases: Scopus, PsycINFO, Web of Science, and Wiley Online Library. A total of 23 studies were selected and data was extracted and tabulated to explore the characteristics of studies on text-based psychotherapy, measurements of the therapeutic alliance and associations of the alliance with treatment outcome. Results: The therapeutic alliance in text-based digital interventions was studied with a variety of client groups, though mostly for clients diagnosed with anxiety and/or depression issues. Treatment modalities were predominantly internet-based cognitive behavioral therapy (ICBT) and tailored platforms for distinct client groups (e.g., PTSD). Almost all treatments used asynchronous text-based communication, such as e-mails and integrated messaging functions, which were mainly used to give feedback on tasks. For measurements, a version of the Working Alliance Inventory (WAI) was used in most studies. Measurements with the WAI or WAI- short form indicated a good therapeutic alliance with a weighted mean score of 5.66 (on a scale of 1 to 7) and a weighted standard deviation of 0.84. Relations between the therapeutic alliance and treatment outcomes were mostly positive, with many studies reporting significant associations (n = 8 out of 10) or significant effects of the therapeutic alliance on treatment outcomes (n = 5 out of 6). Discussion: Our scoping review suggests that a good therapeutic alliance can be established in digital psychotherapy through text-based communication, and shows support for a positive relationship between the alliance and treatment outcomes. These findings illustrate that text-based online psychotherapy can be a responsible treatment option as far as the establishment of the therapeutic alliance is concerned. However, current measures of the therapeutic alliance might miss important aspects of the alliance in digital treatment, such as the presence of empathy or compassion.

Healing in a Social Context: The Importance of Clinician and Patient Relationship

When a patient presents to a health provider, the course of the disorder is composed of three effects: natural effects, specific effects, and contextual effects. Part of the contextual effect is due to the relationship between the healer and the patient. Social healing appears to be present in eusocial species and particularly well-developed in humans. Evidence for the importance of the relationship in healing is found in placebo studies, including placebo analgesics, medicine, and psychotherapy. Although the theory for how the relationship is therapeutic is not well-developed, four possible mechanisms are discussed. The implications for health care and the treatment of pain are discussed.

Online consultations in mental healthcare during the COVID-19 outbreak: An international survey study on professionals' motivations and perceived barriers

INTRODUCTION

While the general uptake of e-mental health interventions remained low over the past years, physical distancing and lockdown measures relating to the COVID-19 pandemic created a need and demand for online consultations in only a matter of weeks.

OBJECTIVE

This study investigates the uptake of online consultations provided by mental health professionals during lockdown measures in the first wave of the COVID-19 pandemic in the participating countries, with a specific focus on professionals' motivations and perceived barriers regarding online consultations.

METHODS

An online survey on the use of online consultations was set up in March 2020. The Unified Theory of Acceptance and Use of Technology (UTAUT) guided the deductive qualitative analysis of the results.

RESULTS

In total, 2082 mental health professionals from Austria, Belgium, Cyprus, France, Germany, Italy, Lebanon, Lithuania, the Netherlands, Norway, Portugal, Spain, and Sweden were included. The results showed a high uptake of online consultations during the COVID-19 pandemic but limited previous training on this topic undergone by mental health professionals. Most professionals reported positive experiences with online consultations, but concerns about the performance of online consultations in a mental health context (e.g., in terms of relational aspects) and practical considerations (e.g., relating to privacy and security of software) appear to be major barriers that hinder implementation.

CONCLUSIONS

This study provides an overview of the mental health professionals' actual needs and concerns regarding the use of online consultations in order to highlight areas of possible intervention and allow the implementation of necessary governmental, educational, and instrumental support so that online consultations can become a feasible and stable option in mental healthcare.

Meeting the Practice Challenges of COVID-19: MSW Students' Perceptions of E-Therapy and the Therapeutic Alliance

The COVID-19 pandemic prompted a radical shift in social work practice. Overnight, social work intervention models provided in-person gave way to the utilization of Information and Communication Technologies to facilitate direct practice in virtual environments (e-therapy). Social work's slow acceptance of e-therapy prior to the pandemic resulted in a lack of training for many social work practitioners and MSW student interns, who were required to make rapid transitions to using and operating in online environments. It appears likely that e-therapy will continue after the COVID-19 pandemic subsides, so integrating education about effective e-therapy techniques into social work curricula seems like a logical next step. A social worker's ability to establish the therapeutic alliance, which is at the heart of all helping relationships, will be central to this curricula. Understanding social work students' perceptions of e-therapy and the therapeutic alliance can help shape the development of this new curriculum. Using internal student email, students at two Research I universities were invited to participate in a fully online anonymous survey dealing with attitudes towards e-therapy and the therapeutic alliance. Surveys were conducted in 2018 and April-May 2020. Survey questions were based on the only prior comprehensive study of student attitudes towards e-therapy (Finn in J Soc Work Educ 38(3), 403-419. 10.1080/10437797.2002.10779107, 2002). Study results indicate that students have e-therapy experience, believe that a practitioner can build a good therapeutic alliance, and think that some form of e-therapy will continue after the pandemic. These results confirm that further exploration about the inclusion of e-therapy education and its efficacy in social work curricula requires urgent attention.