Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3–4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.
The concept of therapeutic alliance, also known as the working alliance, is often regarded as an important ingredient in psychotherapy across different psychotherapy orientations (Lambert & Barley, 2002), but has been studied to a lesser extent in alternative treatment formats such as group therapy and guided self-help. Bordin (1979) introduced a model for understanding therapeutic alliance in which he made distinctions between task, goal and bond, which together form the concept of alliance (Bordin, 1979).
During the last 15 years there has been a rapid development of new ways to deliver cognitive behaviour therapy (CBT), and of these new approaches the internet has probably been the format with the most studies (Andersson, 2009). Many studies on internet-delivered CBT (ICBT) have involved guidance which tends to boost the effect (Andersson & Cuijpers, 2009; Spek, Cuijpers et al., 2007), usually to the extent that guided ICBT and face-to-face therapy yield equivalent outcomes (Bergström et al., 2010; Hedman et al., 2011). Equal outcomes have been found in studies on panic disorder (Bergström et al., 2010; Carlbring et al., 2005; Kiropoulos et al., 2008), social anxiety disorder (Andrews, Davies, & Titov, 2011; Hedman et al., 2011), and subclinical depression (Spek, Nyklicek et al., 2007), but also in studies on conditions like tinnitus (Kaldo et al., 2008).
The role of the therapeutic alliance in guided ICBT is not obvious as there is much less therapist contact than in face-to-face treatments (approximately 1/10 of the time), and that the client may not even see the therapist in person. Still there is a therapeutic interaction as the therapist responds to messages sent from the client and uses both specific and common factors to encourage the client to work with the ICBT (Paxling et al., in press). The development of a therapeutic alliance may not necessarily require direct face-to-face contact with a therapist. It is possible that alliance is at least partly based on client expectations regarding both tasks and goals that may exist before the therapy starts. While the bond between the therapist and the client probably is different in ICBT than in face-to-face therapy questions regarding task, goal and bond are still relevant. Therefore we believe that a therapeutic alliance can be formed over the internet as the therapist in ICBT provides individualized encouragement on progress and also responds to difficulties the client may confront when working with self-help material. Moreover, self-help texts can include aspects that help form a therapeutic alliance and a client may perceive an understanding clinician who is behind the text material (Richardson, Richards, & Barkham, 2010). In other words the total information available for clients when rating the alliance can consist of interactions with a therapist online, interactions with a treatment system, and text material that can possibly boost the alliance.
There has been some previous research on the role of alliance in internet treatments. Cook and Doyle (2002) studied alliance ratings in a small sample (N = 15) and compared the ratings with those from a previous study sample who had received face-to-face therapy. Contrary to expectations the client rated alliance was higher in the online therapy group ( Cook & Doyle, 2002). This finding was replicated in a study on e-mail counselling in which the authors found high ratings of alliance ( D'Arcy, Reynolds, Stiles, & Grohol, 2006), that were within the range of what has been found in face-to-face studies. A limitation of both studies is the lack of a control group as they used previously reported results for the face-to-face comparisons. In a study on posttraumatic stress disorder (PTSD) Knaevelsrud and Maercker (2006) found high ratings of alliance, even if alliance was not a strong predictor of outcome ( Knaevelsrud & Maercker, 2006). However in a subsequent report, the same authors found that alliance scores increased during treatment and that ratings of alliance at the end of treatment correlated with treatment outcome (N = 41) ( Knaevelsrud & Maercker, 2007). Klein, Austin, et al. (2009) and Klein, Mitchell et al. (2009) studied the role of frequency of therapist e-mail contact in a trial on panic disorder. They found no differences in client alliance ratings between the intensive contact condition (average therapist time 308 min) versus the infrequent contact condition (average therapist time 205 min) ( Klein, Austin et al., 2009). The authors concluded that the time spent with the therapist may not be a key variable when rating alliance. Overall, ratings of alliance were high, which the same researchers also found in another study on posttraumatic stress disorder ( Klein, Mitchell, et al., 2009). Correlations with outcome were not reported.
