The Therapeutic Relationship: Does it Exist with Digital Mental Health Services?

The Therapeutic Relationship: Does it Exist with Digital Mental Health Services?

A recent special issue editorial article by Lederman and D’Alfonso (2021) outlines the topic of the therapeutic alliance when delivering psychological therapy online and summarises a number of articles. Some of the key points are presented here.

What is the Therapeutic Alliance (TA)?

The Therapeutic Alliance (TA) is as it sounds – it is a measure of the quality of the relationship between the client or patient and their therapist (Horvath, 1993). Otherwise known as the therapeutic relationship, the TA has long been believed to be a reliable predictor of a positive clinical outcome, with a significant body of literature lending support to this fact.

But given that traditionally therapy occurs in a face-to-face context, can a therapeutic relationship be developed and maintained when occurring in the context of modern day technology?

Digital Mental Health Tools and the Therapeutic Alliance

With the recent shift towards online or digital options for managing mental health and wellbeing, many clinicians and consumers are asking us about the role of the TA in the online treatment space and indeed whether it can be developed?

As a result of the increasing number of online interventions and their associated evaluations a new term has emerged, namely the ‘Digital Therapeutic Alliance’ (DTA). The DTA aims to ‘conceptually capture and measure the therapeutic quality of online psychological therapy or digital mental health interventions’ (Lederman & Alfonso, 2021).

So what exactly is the evidence showing? Can a therapeutic alliance can be developed and maintained in an online mental health treatment space such as a web and mobile based app?

What about the TA and ‘Blended’ therapy?

Blended (or adjunct) treatment refers to the use of an online resource (web based or app) in conjunction with face-to-face treatment. This can be either as a client and practitioner using a resource simultaneously within sessions or a practitioner ‘prescribing’ a resource to work through between-sessions.

Either way, recent research seems to suggest that yes, the therapeutic relationship can be developed and nurtured in this model of care.

Worthy of note is that research also suggests that the digital therapeutic relationship may in some cases be strengthened, likely as a consequence of clients’ enhanced adherence and engagement (Tremain et al., 2020). In particular this has been reported in blended treatment of first-episode psychosis for 18-25 year olds, who report that relationships appeared to be built rather than reduced (Valentine et al., 2020), and blended treatment of people with severe mental illness in a community setting, where the authors recommend that:-

“digital mental health tools should be reframed as tools that can strengthen and augment therapeutic relationships, provided there is a clear shared understanding about how and when they will be used”
(Williams et al., 2021)

Videoconferencing and the TA?

Slightly off-topic for eMHPrac but important nevertheless is the papers discussion of client-psychologist relationships during psychotherapy via videoconferencing.

It is worthy of mention here the forced shift in practice from face-to-face to videoconferencing as a result of the onset of the COVID-19 pandemic. For many this shift in service delivery was unavoidable due to the multiple (and ongoing) lockdowns and isolation. Wind et al (2020) referred to this as a ‘Black Swan Moment’– “an unforeseen event that changes everything” and ultimately leads to ‘a partly, though robust, shift in mental health care provision towards online prevention, treatment, and care in the near future’.

Anecdotally practitioners reported that they were less interested in delivering therapy face-to-face, until there was little choice but to do so. Interestingly, when looking more closely at the experience of psychotherapy videoconferencing for bother therapists and clients, a literature review by Cataldo et al (2021) suggests conflicting results. Specifically clients were generally satisfied that is was possible to establish a therapeutic relationship through video conferencing whereas therapists were less convinced and expressed concern about the quality of the alliance.

Whilst further research is required in this space, from eMHPrac’s perspective this moment signified a surge in interest from health practitioners about what digital resources were available to them and their clients / patients and how they could be utilised in practice.

Final thoughts?

Many practitioners have now been living with the COVID-19 pandemic and delivering therapeutic interventions sporadically online for possibly eighteen months. Whilst literature does remain mixed, there appears to be an increasing body of evidence that the therapeutic alliance can indeed be developed and maintained in the online space. This said more research is needed focusing on the DTA and how it can be measured. This work is clearly underway with the development of tools such as the Mobile Agnew Relationship Measure (mARM) (Berry et al., 2018) and the eTAP-T (Clough  et al.,2019)