An investigation of session impact and alliance in internet based psychotherapy: Preliminary results

Client resources and the prediction of therapeutic change using an interview: An exploratory study

OBJECTIVES

Although psychotherapy research suggests that clients' resources are related to positive outcomes, there is a lack of clinical tools available to consider their integration into psychotherapy. In this exploratory research, we studied the feasibility of a semi-structured interview to identify resources reported by clients at the onset of therapy and the relationship between resources and therapy outcomes.

METHODS

Data consisted of interviews with 30 clients from a clinical trial, in which elicitation of resources and their relationship with the outcomes were the main study objectives.

RESULTS

This interview was content analyzed and both adaptative resources and maladaptive resources (dysfunctional coping strategies) were identified. The association between the adaptive resources and the evolution of outcomes throughout treatment was analyzed. Time (i.e. sessions) and resources were negatively correlated with psychological distress. Moreover, resources positively influenced the impact of time on distress.

CONCLUSIONS

Clinicians should not take at face value resources that are self-reported, as they may reflect the maladaptive functioning of the client. The finding that clients with higher resources at onset have better outcomes points to the need to study how resources may be elicited effectively during therapy, and if this improves psychotherapy outcomes.

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.

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.

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.

"When the first session may be the last!": A case report of the implementation of "rapid tele-psychotherapy" with single-session music therapy in the COVID-19 outbreak

Objective

Conventional psychotherapy with a lengthy and regular number of meetings is no longer relevant in the case of COVID-19, when persons with psychiatric problems, especially COVID-19 patients/clients, really require immediate psychological assistance. It is recognized as a “rapid test” in the field of body health to rapidly decide whether or not a person is affected by COVID-19. So, we should now be able to use the term “rapid tele-psychotherapy” with Single-Session Music Therapy (SSMT) in the field of mental health to characterize the mechanism of assistance provided to persons who seek therapeutic assistance virtually during this COVID-19 outbreak, so that they will easily and reliably be freed from troubling psychiatric issues.

Method

The author reports the case of a 33-year-old widow with asymptomatic COVID-19 who was admitted to her own home.

Results

The author describes the effectiveness of the implementation of rapid tele-psychotherapy with SSMT in reducing the scale of anxiety, panic, fear, depression, acute stress, insomnia, and delusions of death.

Significance of results

This case can provide new inputs or ideas for counselors/psychologists/psychiatrists/therapists who work in hospitals/institutions to provide rapid tele-psychotherapy with SSMT as therapeutic assistance for individuals who need psychotherapy in this COVID-19 outbreak, especially for COVID-19 patients/clients. Besides that, this concept is not only suitable for rapidly screening individuals that may face psychological problems and helping them better seek therapeutic assistance, but can also be used as an adjuvant therapy for psychiatric patients.

Virtual Delivery of Therapeutic Assessment: An Empirical Case Study

The Therapeutic Assessment (TA) model of psychological assessment has grown in use due to the demonstrated benefits to clients. However, to date, there have been no published articles on how conducting TA virtually may impact the process and experience. The COVID-19 global pandemic led to a rapid increase in virtual delivery of psychological services, including assessments. Assessors adapted procedures to ensure that clients were served ethically, the assessor-client relationship was considered, and the results were deemed valid. This empirical case study was conducted to evaluate test validity, therapeutic alliance, and the clinician's and client's experience of a TA conducted virtually. The validity of test administration was evaluated by experts, who reviewed video of the administration and test results; no concerns regarding integrity and interpretability of the results were identified. Therapeutic alliance, session process, and virtual presence were measured after each session. Both clinician and client reported positive experiences. The overall impact of the TA was evaluated through quantitative assessment of the client's experience and qualitative analysis of interviews. Collectively, this research demonstrates the feasibility of conducting a TA virtually, in an efficacious manner, that leads to positive client outcomes.

Internet-based cognitive behavioural therapy programme with and without videoconference guidance sessions: A randomized controlled trial to treat work-related symptoms of anxiety and depression

This study provides the results from the implementation of a highly structured therapist-guided iCBT programme for people with work-related anxiety and depression, in terms of programme efficacy, participants' adherence and satisfaction. Seventy-seven national police workers were randomly allocated to one of two groups: without additional videoconference sessions (web platform with guidance of therapist) and with additional videoconference sessions (same intervention as the previous group, plus two videoconference guidance sessions with a psychologist). The intervention was composed of 12 sessions and took place for 17-20 weeks. We found an adherence rate of 36.4%, with no differences between groups. All participants endorsed lower depression (BDI-II F(1) = 36.98, p < .001; ATQ F(1) = 24.22, p < .001), and anxiety (STAI-State F(1) = 76.62, p < .001) after the programme. As a variable related to anxiety and depression in workplace, participants also showed higher assertiveness levels (RAS F(1) = 8.96, p < .001). A significant reduction of the mean level of anxiety perceived by participants as the intervention programme progressed was observed in both groups (F(2) = 7.44; p = .003). Participants were satisfied with the therapists' intervention and with the programme. No significant group effects were found for any of the measures. Reduction in depression levels was maintained in the 12-month follow-up, but levels of anxiety increased. This study is innovative, as it is the first controlled trial to analyse the effect of two added videoconference sessions, and it includes short- and long-term measures, which is not usual. The results are discussed to clarify the role of the contact with the therapist to improve treatment adherence.

Online/Cyber Counseling Services in the COVID-19 Outbreak: Are They Really New?

Online/cyber counseling has been named as the best way to offer counseling services during the COVID-19 outbreak. The purpose of this article is to explore the use of online/cyber counseling during the COVID-19 outbreak to solve psychological problems. The author examines the history and concepts, the therapeutic relationship, transference and countertransference, the advantages along with the disadvantages, considerations, implications, and curriculum for online/cyber counseling during COVID-19 outbreak.

Two-way messaging therapy for depression and anxiety: longitudinal response trajectories

BACKGROUND

Telemedicine is a strategy for overcoming barriers to access evidence-based psychotherapy. Digital modalities that operate outside session-based treatment formats, such as ongoing two-way messaging, may further address these challenges. However, no study to date has established suitability criteria for this medium.

METHODS

A large outpatient sample (n = 10,718) engaged in daily messaging with licensed clinicians from a telemedicine provider. Patients consisted of individuals from urban and rural settings in all 50 states of the US, who signed up to the telemedicine provider. Using a longitudinal design, symptoms changes were observed during a 12 week treatment course. Symptoms were assessed from baseline every three weeks using the Patient Health Questionnaire (PHQ-9) for depression, and the Generalized Anxiety Disorder (GAD-7) for anxiety. Demographics and engagement metrics, such as word count for both patients and therapists, were also assessed. Growth mixture modeling was used to tease apart symptoms trajectories, and identify predictors of treatment response.

RESULTS

Two subpopulations had GAD-7 and PHQ-9 remission outcomes (Recovery and Acute Recovery, 30.7% of patients), while two others showed amelioration of symptoms (Depression and Anxiety Improvement, 36.9% of patients). Two subpopulations experienced no changes in symptoms (Chronic and Elevated Chronic, 32.4% of patients). Higher use of written communication, patient characteristics, and engagement metrics reliably distinguished patients with the greatest level of remission (Recovery and Acute Recovery groups).

CONCLUSIONS

Remission of depression and anxiety symptoms was observed during delivery of psychotherapy through messaging. Improvement rates were consistent with face-to-face therapy, suggesting the suitability of two-way messaging psychotherapy delivery. Characteristics of improving patients were identified and could be used for treatment recommendation. These findings suggest the opportunity for further research, to directly compare messaging delivery with a control group of treatment as usual.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT03699488, Retrospectively Registered October 8, 2018.

Feasibility, Acceptability, and Preliminary Impacts of Web-Based Patient Education on Patients With Schizophrenia Spectrum Disorder: Quasi-Experimental Cluster Study

BACKGROUND

Web-based interventions are promising tools for increasing the understanding of illness and treatment among patients with serious mental disorders.

OBJECTIVE

This study aimed to test the feasibility and acceptability of a Web-based patient education intervention using a quasi-experimental cluster design to report feedback on patient education sessions and the website used and to report preliminary evidence of the intervention's impact on patients with schizophrenia spectrum disorder.

METHODS

A single-blind, parallel, quasi-experimental cluster study over a 6-month period comparing Web-based education (n=33) with a nonequivalent control group (treatment as usual, n=24) for people with schizophrenia spectrum disorder was conducted. Participants (N=57) were recruited from one psychiatric hospital (6 wards). Feasibility was assessed by participants' commitment (refusal rate, dropout rate) to the study. Acceptability was assessed as participants' commitment to the intervention. Patient education sessions and website feedback were assessed by the patients and health care professionals. The preliminary impact of the sessions on patients' self-efficacy, self-esteem, illness cognition, and knowledge level was measured at baseline and follow-ups (8 weeks, 6 months) with self-rated questionnaires.

RESULTS

The refusal rate among patients was high with no statistically significant difference (69% [74/107] in the intervention group, 76% [76/100] in the control group; P=.21). The same result was found for the dropout rates (48% [16/33] vs 58% [14/24]; P=.46). The acceptability of the intervention was good; 31 participants out of 33 (94%) completed all five sessions. Feedback on the intervention was mainly positive; three out of four subscales of session were rated above the midpoint of 4.0. Feedback on the website was also positive, with a grade of good for content (69%, 20/29 patients; 75%, 21/28 professionals), layout (62%, 18/29 patients; 61%, 17/28 professionals), and usability (62%, 18/29 patients; and 68%, 19/28 professionals). The patients using the intervention had significantly higher scores 6 months after the sessions in self-efficacy (baseline mean 26.12, SD 5.64 vs 6-month mean 29.24, SD 6.05; P=.003) and regarding knowledge level about schizophrenia (mean 11.39, SD 4.65 vs 6-month mean 15.06, SD 5.26; P=.002), and lower scores in the subscale of helplessness in illness cognition (mean 2.26, SD 0.96 vs 6-month mean 1.85, SD 0.59; P=.03). Differences from the control group were not significant. No differences were found in patients' self-esteem or other subscales in illness cognition.

CONCLUSIONS

The patients were reluctant to participate in the study and tended to drop out before the follow-ups. Once they had participated, their acceptance of the intervention was high. A more effective recruitment strategy and monitoring method will be needed in future studies. To assess the impact of the intervention, a more rigorous study design with an adequately powered sample size will be used in cooperation with outpatient mental health services.

Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders - A systematic review

OBJECTIVE

The role of internet therapy programs for mental disorders is growing. Those programs employing human support yield better outcomes than do those with no such support. Therapeutic alliance may be a critical element in this support. Currently, the significance of therapeutic alliance in guided, internet-delivered cognitive behavioral therapy programs (iCBT) remains unknown. This review aims to determine whether the therapeutic alliance influences outcome of iCBTs and if it does, what plausible factors underlie this association.

METHOD

Towards that goal searches were made in PubMed, PsycINFO, SCOPUS, The Cochrane Library and CINAHL in May 2016 and January 2017.

RESULTS

From the 1658 relevant studies, only six studied the relationship of therapeutic alliance and outcome. All six studies showed a high level of client-therapist alliance; in the three most recent studies, the alliance was directly associated with outcome. No studies reported alliance-adherence associations.

CONCLUSIONS

Alliance research in iCBT for mental disorders is scarce. Therapeutic alliance seems to associate with outcomes. More studies are necessary to define the optimal support to strengthen alliance. iCBT is a feasible environment for alliance research both practically and theoretically. The impact of alliance on adherence to iCBT requires study.

Research on the alliance: Knowledge in search of a theory

OBJECTIVES

The aim of this review paper is to summarize the challenges facing research on the alliance now and going forward. The review begins with a brief overview of the development of the concept of the alliance in historical context.

METHOD

A summary of what has been accomplished both within the psychotherapy research community and in other professions is presented. Current challenges facing this line of research are identified, including the existence of a wide range of operational definitions that results in a diffusion of the identity of the alliance concept. It is argued that the current situation generates risks to incremental growth in several lines of research.

CONCLUSIONS

A case is made that a lack of clarity regarding how several variables within the broader category of therapeutic relationships fit together, overlap, or complement each other is also potentially problematic. Efforts to resolve the lack of a consensual definition are reviewed, and in conclusion, it is argued that a resumption of a conversation about the relationship in the helping context in general, and the alliance in particular, should be resumed.

Defining the Role of the Online Therapeutic Facilitator: Principles and Guidelines Developed for Couplelinks, an Online Support Program for Couples Affected by Breast Cancer

Development of psychological interventions delivered via the Internet is a rapidly growing field with the potential to make vital services more accessible. However, there is a corresponding need for careful examination of factors that contribute to effectiveness of Internet-delivered interventions, especially given the observed high dropout rates relative to traditional in-person (IP) interventions. Research has found that the involvement of an online therapist in a Web-based intervention reduces treatment dropout. However, the role of such online therapists is seldom well articulated and varies considerably across programs making it difficult to discern processes that are important for online therapist involvement.In this paper, we introduce the concept of "therapeutic facilitation" to describe the role of the online therapist that was developed and further refined in the context of a Web-based, asynchronous psychosocial intervention for couples affected by breast cancer called Couplelinks. Couplelinks is structured into 6 dyadic learning modules designed to be completed on a weekly basis in consultation with a facilitator through regular, asynchronous, online text-based communication.Principles of therapeutic facilitation derived from a combination of theory underlying the intervention and pilot-testing of the first iteration of the program are described. Case examples to illustrate these principles as well as commonly encountered challenges to online facilitation are presented. Guidelines and principles for therapeutic facilitation hold relevance for professionally delivered online programs more broadly, beyond interventions for couples and cancer.

Clinicians' attitudes toward therapeutic alliance in E-therapy

Although therapeutic alliance is a crucial factor in face-to-face therapies, no data exist on clinicians' attitudes towards alliance in E-therapy. The study explored clinicians' perceived importance of alliance in E-therapy, clinicians' confidence in their skills to develop alliance in E-therapy, and whether attitudes towards alliance in E-therapy are associated with intended E-therapy practice. Clinicians (n = 106) responded to an online survey. The majority of clinicians considered alliance to be extremely important in both face-to-face therapy and E-therapy. However, clinicians' ratings of the importance of alliance in face-to-face therapies were significantly higher than their ratings of the importance of alliance in E-therapy. Clinicians reported less confidence in their skills to develop alliance in E-therapy than in face-to-face therapy. Intended E-therapy practice correlated with confidence in one's ability to develop alliance in E-therapy and with previous E-therapy practice.

Feasibility study of an interactive multimedia electronic problem solving treatment program for depression: a preliminary uncontrolled trial

Computer-based depression interventions lacking live therapist support have difficulty engaging users. This study evaluated the usability, acceptability, credibility, therapeutic alliance and efficacy of a stand-alone multimedia, interactive, computer-based Problem Solving Treatment program (ePST™) for depression. The program simulated live treatment from an expert PST therapist, and delivered 6 ePST™ sessions over 9weeks. Twenty-nine participants with moderate-severe symptoms received the intervention; 23 completed a minimally adequate dose of ePST™ (at least 4 sessions). Program usability, acceptability, credibility, and therapeutic alliance were assessed at treatment midpoint and endpoint. Depressive symptoms and health-related functioning were assessed at baseline, treatment midpoint (4weeks), and study endpoint (10weeks). Depression outcomes and therapeutic alliance ratings were also compared to previously published research on live PST and computer-based depression therapy. Participants rated the program as highly usable, acceptable, and credible, and reported a therapeutic alliance with the program comparable to that observed in live therapy. Depressive symptoms improved significantly over time. These findings also provide preliminary evidence that ePST™ may be effective as a depression treatment. Larger clinical trials with diverse samples are indicated.

Psicoterapia pela Internet: viável ou inviável?

A psicoterapia pela internet é uma prática que, no Brasil, só é permitida aos psicólogos na forma de pesquisa. O objetivo do presente artigo foi realizar uma revisão dos estudos em psicoterapia pela internet, discorrendo sobre os recursos e os limites desse atendimento psicológico e suas implicações para a relação terapêutica e para a efetividade do tratamento. São apresentadas questões legais e éticas concernentes à prática. Os resultados apontaram similaridades entre a relação terapêutica online e a presencial, mostrando-se a psicoterapia pela internet efetiva nas mais distintas modalidades, embora a maioria dos estudos seja sobre intervenções cognitivo-comportamentais. As questões legais e éticas podem ser parcialmente solucionadas com diretrizes claras das organizações profissionais e com o treino de terapeutas na modalidade online. Concluímos que a psicoterapia pela internet, embora requeira maiores estudos, anuncia-se como uma prática viável e promissora.

Perceptions of two therapeutic approaches for palliative care patients experiencing death anxiety

Objective:

Evidenced-based psychotherapies are not well researched for palliative care patients experiencing unrelenting anxiety about dying, even less research is focused on young adult palliative care patients with death anxiety. The aim of this study is to provide preliminary data regarding potential clients' perceptions of using evidenced based treatments with dying populations who are experiencing death anxiety.

Methods:

104 college students were used as potential clients and randomly assigned to watch either a short video of a cognitive therapy (CT) session or of an acceptance and commitment therapy (ACT) session focused on treating a young adult diagnosed with an acute lymphoid leukemia expressing death anxiety. After watching the video, potential clients rated the session impact of the therapy approach using the Session Evaluation Questionnaire.

Results:

No differences in ratings of session impact were found between potential clients who viewed the CT session and the ACT session. In regards to potential clients' views of session impact variables, their view of session smoothness was positively related to their post-session positivity, but inversely related to their view of session depth. Additionally, a positive correlation was found between potential clients' views of the therapist and session depth.

Significance of results:

This preliminary study suggests that palliative care patients expressing death anxiety may benefit from either ACT or CT for death anxiety, however, future research is needed to explore the usefulness of each approach. Findings of this study support the theory that ACT and CT are viewed to have a similar session impact in the palliative care population.

Impact of exchanges and client-therapist alliance in online-text psychotherapy

The impact of exchanges and client-therapist alliance of online therapy text exchanges were compared to previously published results in face-to-face therapy, and the moderating effects of four participant factors found significant in previously published face-to-face studies were investigated using statistical mixed-effect modeling analytic techniques. Therapists (N=30) and clients (N=30) engaged in online therapy were recruited from private practitioner sites, e-clinics, online counseling centers, and mental-health-related discussion boards. In a naturalistic design, they each visited an online site weekly and completed the standard impact and alliance questionnaires for at least 6 weeks. Results indicated that the impact of exchanges and client-therapist alliance in text therapy was similar to, but in some respects more positive than, previous evaluations of face-to-face therapy. The significance of participant factors previously found to influence impact and alliance in face-to-face therapy (client symptom severity, social support, therapist theoretical orientation, and therapist experience) was not replicated, except that therapists with the more symptomatic clients rated their text exchanges as less smooth and comfortable. Although its small size and naturalistic design impose limitations on sensitivity and generalizability, this study provides some insights into treatment impact and the alliance in online therapy.

Cognitive behaviour therapy (CBT) for depression by computer vs. therapist: patient experiences and therapeutic processes

Abstract This case series compares patient experiences and therapeutic processes between two modalities of cognitive behaviour therapy (CBT) for depression: computerized CBT (cCBT) and therapist-delivered CBT (tCBT). In a mixed-methods repeated-measures case series, six participants were offered cCBT and tCBT in sequence, with the order of delivery randomized across participants. Questionnaires about patient experiences were administered after each session and a semi-structured interview was completed with each participant at the end of each therapy modality. Therapy expectations, patient experiences and session impact ratings in this study generally favoured tCBT. Participants typically experienced cCBT sessions as less meaningful, less positive and less helpful compared to tCBT sessions in terms of developing understanding, facilitating problem-solving and building a therapeutic relationship.

Die Evaluation von Therapiesitzungen durch Patienten und Therapeuten

Das Session Evaluation Questionnaire (SEQ) wurde ins Deutsche übersetzt. Es erfasst die unmittelbaren Auswirkungen einer Therapiesitzung in je eigener Version für Patienten und Therapeuten. Primäres Ziel der Untersuchung war die Replikation der Faktorstruktur, sekundäres Ziel die Bestimmung der Übereinstimmung der Patienten- und Therapeutensicht. Die Stichprobe umfasst 1164 Therapiesitzungen aus 98 Therapien (26 Therapeuten) zu denen aus Patienten- und Therapeutensicht das SEQ erhoben wurde. Für beide Perspektiven wurde mittels Konfirmatorischer Mehrebenen Faktoranalyse die Anpassungsgüte der amerikanischen Faktorlösung überprüft. Die Faktoren Tiefe, Fluss & Positivität des SEQ lassen sich in der deutschen Version replizieren. Der vierte Faktor „Aufregung” erweist sich für die deutsche Version des SEQ als nicht reliabel. Patienten- und Therapeutensicht einer Stunde sind wenig konvergent. Der SEQ-D steht als deutschsprachiges, international vergleichbares und therapie-schulenübergreifendes Instrument für Psychotherapieprozessforschungsfragen zur Verfügung.

Barriers to mental health care: perceived delivery system differences

Treatment barriers have prompted the development of new models of care. Distance delivery systems bridge the access gap, increasing service availability. Understanding differences between systems can inform system improvements. Sixty participants from the Strongest Families telephone intervention for child behavior difficulties participated. Participants completed a questionnaire to explore differences in perceived treatment barriers (Treatment Barriers Index-TBI) and therapeutic processes (eg, therapeutic alliance, self-disclosure, health outcome) between face-to-face versus distance treatment. The TBI scale has strong internal reliability (Cronbach α: 0.95 [face-to-face]; 0.90 [distance]). Statistically significant differences were found between delivery system TBI mean scores, indicating fewer barriers with distance treatment. Therapeutic process differences between delivery modes suggest enhanced therapeutic alliance and self-disclosure scores with distance treatment. Increased access, convenience, and sense of privacy (visual anonymity) offered by a distance delivery system may provide an enhanced experience for some individuals.

The therapeutic relationship in e-therapy for mental health: a systematic review

Background

E-therapy is defined as a licensed mental health care professional providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these. The use of e-therapy has been rapidly expanding in the last two decades, with growing evidence suggesting that the provision of mental health services over the Internet is both clinically efficacious and cost effective. Yet there are still unanswered concerns about e-therapy, including whether it is possible to develop a successful therapeutic relationship over the Internet in the absence of nonverbal cues.

Objective

Our objective in this study was to systematically review the therapeutic relationship in e-therapy.

Methods

We searched PubMed, PsycINFO, and CINAHL through August 2011. Information on study methods and results was abstracted independently by the authors using a standardized form.

Results

From the 840 reviewed studies, only 11 (1.3%) investigated the therapeutic relationship. The majority of the reviewed studies were focused on the therapeutic alliance—a central element of the therapeutic relationship. Although the results do not allow firm conclusions, they indicate that e-therapy seems to be at least equivalent to face-to-face therapy in terms of therapeutic alliance, and that there is a relationship between the therapeutic alliance and e-therapy outcome.

Conclusions

Overall, the current literature on the role of therapeutic relationship in e-therapy is scant, and much more research is needed to understand the therapeutic relationship in online environments.

Therapist Behaviours in Internet-Delivered Cognitive Behaviour Therapy: Analyses of E-Mail Correspondence in the Treatment of Generalized Anxiety Disorder

Background: Internet-delivered cognitive behaviour therapy (iCBT) has been found to be an effective way to disseminate psychological treatment, and support given by a therapist seems to be important in order to achieve good outcomes. Little is known about what the therapists actually do when they provide support in iCBT and whether their behaviour influences treatment outcome. Aims: This study addressed the content of therapist e-mails in guided iCBT for generalized anxiety disorder. Method: We examined 490 e-mails from three therapists providing support to 44 patients who participated in a controlled trial on iCBT for generalized anxiety disorder. Results: Through content analysis of the written correspondence, eight distinguishable therapist behaviours were derived: deadline flexibility, task reinforcement, alliance bolstering, task prompting, psychoeducation, self-disclosure, self-efficacy shaping, and empathetic utterances. We found that task reinforcement, task prompting, self-efficacy shaping and empathetic utterances correlated with module completion. Deadline flexibility was negatively associated with outcome and task reinforcement positively correlated with changes on the Penn State Worry Questionnaire. Conclusions: Different types of therapist behaviours can be identified in iCBT, and though many of these behaviours are correlated to each other, different behaviours have an impact on change in symptoms and module completion.

Two short forms of the Agnew Relationship Measure: the ARM-5 and ARM-12

This article reports the development and psychometric properties of two short forms of the 28-item Agnew Relationship Measure, the ARM-12 and ARM-5. For the ARM-12, results of previous research were used together with conceptual considerations to select three items to represent each of four ARM subscales: Bond, Partnership, Confidence, and Openness. For the ARM-5, item-analytic principles were used to select five items to represent overall alliance. In all three ARMs, client and therapist versions were constructed to contain parallel items. We drew data to assess reliability and validity from three UK trials of brief therapy for depression. Results indicated that the two short ARMs have acceptable psychometric properties and that they converged with each other and with the full ARM.

The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression

BACKGROUND

Although numerous efficacy studies in recent years have found internet-based interventions for depression to be effective, there has been scant consideration of therapeutic process factors in the online setting. In face-to face therapy, the quality of the working alliance explains variance in treatment outcome. However, little is yet known about the impact of the working alliance in internet-based interventions, particularly as compared with face-to-face therapy.

METHODS

This study explored the working alliance between client and therapist in the middle and at the end of a cognitive-behavioral intervention for depression. The participants were randomized to an internet-based treatment group (n = 25) or face-to-face group (n = 28). Both groups received the same cognitive behavioral therapy over an 8-week timeframe. Participants completed the Beck Depression Inventory (BDI) post-treatment and the Working Alliance Inventory at mid- and post- treatment. Therapists completed the therapist version of the Working Alliance Inventory at post-treatment.

RESULTS

With the exception of therapists' ratings of the tasks subscale, which were significantly higher in the online group, the two groups' ratings of the working alliance did not differ significantly. Further, significant correlations were found between clients' ratings of the working alliance and therapy outcome at post-treatment in the online group and at both mid- and post-treatment in the face-to-face group. Correlation analysis revealed that the working alliance ratings did not significantly predict the BDI residual gain score in either group.

CONCLUSIONS

Contrary to what might have been expected, the working alliance in the online group was comparable to that in the face-to-face group. However, the results showed no significant relations between the BDI residual gain score and the working alliance ratings in either group.

TRIAL REGISTRATION

ACTRN12611000563965.

Volunteer and user evaluation of the National Sexual Assault Online Hotline

PURPOSE

The National Sexual Assault Online Hotline (NSAOH) is a new model for delivery of rape and sexual assault crisis services through a secure, confidential chat-based online hotline. This paper presents a program evaluation drawn from volunteer counselor and user perceptions and experiences during the second year of operation of the NSAOH.

METHOD

Outcome data are presented from 731 session evaluations submitted by 94 volunteers and session evaluations from 4609 user sessions collected between June 1, 2008 and May 30, 2009. Evaluation includes ratings of usefulness, topics discussed, length of sessions, services provided, and session difficulties.

RESULTS

The results indicate that the model is viable and useful, and the majority of volunteers and users are satisfied. Volunteer knowledge and skills are strongly associated with satisfaction with the hotline. Nevertheless, one-fifth of volunteers rate their session as not useful and users rate 8.2% of volunteers low in knowledge and skills.

DISCUSSION

NSAOH is reaching many who have not previously sought services or did not resolve issues through other means. Findings suggest the importance of preparing volunteers in both crisis intervention and a wide variety of long-term issues related to sexual assault. Recommendations for program development, evaluation, and further research are presented.

The use of email as a component of adult stammering therapy: a preliminary report

In West Glasgow email has evolved from a rapid means of arranging therapy appointments with adults who stammer into a medium for exchange of therapeutic messages with some clients. Since 2004, sixteen clients have used email to communicate as part of their therapy programme. The benefits include improving access to services, supporting speech change, facilitating lasting personal growth, improving clinical decision-making, equalizing the therapist-client relationship and enhancing caseload management. Although this experience suggests that email is appropriate for stammering therapy, the effectiveness and ethics of, and the rationale for, clinical practice that includes email need careful consideration. Further research is required to formally evaluate the client experience.

Therapist effects in guided internet-delivered CBT for anxiety disorders

BACKGROUND

Guided internet-delivered CBT for anxiety disorders has received increasing empirical support, but little is known regarding the role of the therapist.

AIMS

This study addressed therapist factors in guided internet-delivered cognitive behavioural therapy for anxiety disorders.

METHOD

Data from three controlled trials with a total N of 119 were analyzed with attention to differences between eight therapists.

RESULTS

No significant mean level differences between therapists appeared in the dataset. However, one significant intraclass correlation between participants was found, suggesting that the outcome on the Beck Anxiety Inventory might have been influenced by the impact of the individual therapists.

CONCLUSION

The therapist can possibly have some influence on the outcome of guided internet-delivered CBT for anxiety disorders, but studies with more statistical power are needed to establish whether therapist effects are present in this modality of psychological treatment. The present study was underpowered to detect minor therapist effects.