Understanding Components of Therapeutic Alliance and Well-Being from Use of a Global Digital Mental Health Benefit During the COVID-19 Pandemic: Longitudinal Observational Study

Abstract

Digital mental health services leverage technology to increase access to care, yet less is known about the quality of therapeutic relationships in a virtual setting. This study examined components of therapeutic alliance (a mechanism underlying successful treatment) and its association with beneficial treatment outcomes in a real-world, virtual setting. The objective is to examine (1) participant ratings of components of therapeutic alliance with providers in a virtual setting, (2) changes in subjective well-being and depressive symptoms among participants who began care with elevated depressive symptoms, and (3) the association between components of alliance and changes in participants’ well-being. Adults (N = 3,087, M age = 36 ± 9 years, 54% female) across the world with access to digital mental health benefits who engaged in videoconference sessions with a licensed therapist (18%, 555/3,087), certified coach (65%, 2,003/3,087), or both (17%, 529/3,087) between Sept. 29, 2020 and Oct. 12, 21. Participants completed 2 adapted items from the Working Alliance Inventory (goals and bonds subscales) after each session, and ratings were averaged across visits (Cronbach’s ɑ = .72). Participants’ World Health Organization-Five (WHO-5) Well-Being Index scores at the start and end of the study period were used to measure changes in subjective well-being. Descriptive and inferential statistics were conducted to examine average alliance ratings across demographics and utilization types and the association between alliance and well-being. The median adapted therapeutic alliance score was 4.8 (range: 1–5) and did not differ by age, country, or baseline well-being (Ps > .07). Females reported higher components of alliance than males (4.88 vs. 4.67, P = .01). Participants utilizing telecoaching reported higher components of alliance than those utilizing teletherapy or both telecoaching and teletherapy (4.83 v. 4.75, P = .004), though effect sizes were negligible. Among those with elevated baseline depressive symptoms (n = 835), participants reported an average WHO-5 increase of 15.42 points (95% CI 14.19–16.65, P < .001, Cohen d = 1.06) with 58% (485/835) reporting clinical recovery and 57% (481/835) reporting clinical improvement in depressive symptoms. Higher components of therapeutic alliance scores predicted greater well-being at follow-up (b = 2.04, 95% CI 0.09–3.99, P = .04) after controlling for age, sex, baseline WHO-5, and number of days in care (R2 = .06, P < .001). Exploratory analyses indicated this association did not differ by utilization type, baseline well-being, or session utilization (Ps > .34). People with access to one-on-one videoconferencing care via a digital mental health benefit formed a strong bond and sense of alignment on goals with both coaches and therapists. Higher components of alliance scores were associated with improvements in subjective well-being among participants who began care with elevated depressive symptoms, providing evidence that a positive bond and goal alignment with a provider are two of many factors influencing virtual care outcomes. Continued focus on the quality of therapeutic relationships will ensure digital mental health services are patient-tailored as these platforms expand equitable access to evidence-based care.

Effect of Sleep Duration on Blood Pressure in Patients with SARS-CoV-2 Infection and Hypertensive Urgencies in Shanghai Fangcang Shelter Hospital

“…[17][18][19] Furthermore, the resultant increase in physical stress may lead to anxiety, depression, and sleep disorders. [20][21][22] In the Fangcang shelter hospital, there is continuous bright light intensity even at night. Most patients with SARS-CoV-2 infection already exhibit respiratory symptoms such as cough and fever, and gastrointestinal symptoms such as nausea, anorexia, and diarrhea.…”

A randomised controlled test of emotional attributes of a virtual coach within a virtual reality (VR) mental health treatment

“…Therapeutic alliance, a positive relationship between patient and therapist, is a reliable predictor of better mental health treatment outcomes 3 , 4 , and even affects the efficacy of psychological treatments delivered in digital forms 5 – 7 . Similarly, patient belief in the credibility of a therapy offered, and expectations of successful outcomes, predict better treatment outcomes 8 , 9 .…”

The Experiences of Psychotherapists Delivering Therapy During the Shared Crisis of a Pandemic

“…Emerging research on the impact of COVID‐19 on the therapeutic alliance has suggested what was vital to successfully navigating therapy during the pandemic (Cioffi et al ., 2020; Fernández‐Álvarez & Fernández‐Álvarez, 2021; Geller, 2021; Grignoli, Arnaboldi & Antonini, 2021; Zubala & Hackett, 2020; van Lotringen et al ., 2021). Several studies found that therapeutic alliance was not significantly altered by online therapy delivery (Earle & Freddolino, 2022; Eichenberg et al ., 2022; Lange et al ., 2022; Leuchtenberg, Gromer & Käthner, 2023; Sagui‐Henson et al ., 2022).…”