Therapist rated alliance can predict outcome in blended Cognitive Behaviour Therapy for depression

How important is alliance in blended Cognitive Behaviour Therapy? That is the research question that we tried to answer in this study that was conducted at Linköping University as part of a larger European project (the E-COMPARED project) on blended treatment for depression. The study was also included in a dissertation on alliance and different internet-based treatment formats for depression (

It is yesterday’s news that depression is a widespread mental disorder that has extensive disabling effects all over the Europe and the rest of the world. But even though we know there are several effective treatments for depression, there is currently a lack of therapists and access to effective treatment in the regular health care. One way of reaching more patients is by combining therapist face-to-face sessions with internet-based material, defined as blended cognitive behaviour therapy (bCBT). Using blended treatments as this could provide specific advantages such as decreasing the costs of treatment and at the same time making it possible to adapt and individualize treatment to make it more effective. Surveys in European health care contexts have shown that stakeholders in regular health care hold positive attitudes towards blended interventions, which could facilitate the implementation of blended treatment in clinical settings and thereby increase the access to effective care.

Another question of importance is the role of alliance in psychological treatment. The therapeutic relationship and alliance have been conceptualized and measured in many ways and is considered an important aspect of most therapeutic interventions. Usually, patient-rated alliance measures have been used in research studies, but alliance can also be measured by therapists. Ratings by therapists can be a useful tool in clinical settings as therapist themselves could perform ratings of their interactions with patients and from the results predict the potential outcome of the therapeutic intervention they are delivering.

Participants in this study were recruited from three mental health care centres in Sweden. A total of 306 individuals signed up for the study and 147 participants were included. A total of 73 of these were randomly allocated to the bCBT. These participants received four live sessions with a therapist and 10 online modules during the treatment period of 10 weeks. The main content of the bCBT treatment consisted of psychoeducation, behavioural activation, cognitive restructuring, and relapse prevention. Depression was measured weekly during treatment with Patient Health Questionnaire (PHQ-9) and alliance at week four with two different versions of the Working Alliance Inventory – Short Revised version (WAI-SR-C, WAI-SR-T). Data was analysed using growth models, modeling individual change rate, examining if working alliance could predict subsequent changes in depression during treatment. Depression measurements at week three was used to control for reduction in depression.

Our main finding was that the therapist-rated alliance predicted changes in depression during treatment, but patient-rated alliance did not. To the best of our knowledge, this is a new finding that has not been observed previously, neither with face-to-face nor internet-based treatments. The growth model showed a change rate of 0.5 per week, indicating that a one-point increase on WAI-SR-T (a higher alliance) was associated with a total of 3.5 points less depression rated by PHQ-9 from week four to post-treatment. Also, alliance ratings were high and similar to alliance ratings in face-to-face studies, indicating that a positive relationship was formed between therapists and participants.

Except from confirming that online interactions in therapy and an internet-based delivery of content does not affect alliance in a negative way, this study also matches earlier research showing that from the patients perspective, alliance might not be as important in treatments that are highly structured and self-help based. Another conclusion could be that therapist-rated alliance is a better measure of the actual alliance between therapist and patient in blended treatment. This could be so because participants in the study rated their alliance in relation to the whole treatment package, including the self-help material online, whereas therapist rated their alliance based on the interaction with participants during the treatment period. Since earlier studies has shown that self-help material also can include alliance bolstering components, it could be more difficult to differentiate the role of patient-rated alliance in relation to the internet-therapist.

Blended treatment is a new form of treatment with promising results. More research is needed regarding how best to deliver this treatment and what role alliance plays in this specific type of delivery, mixing traditional face-to-face interaction and online CBT components. Looking at the results from this study, it could be that therapist alliance is more useful than patient-rated alliance when trying to foresee the effects of blended treatment. It also addresses the need to develop and use questionnaires that are adapted to the inclusion of online self-help material in the treatment of depression.

Read the full paper: Vernmark, K., Hesser, H., Topooco, N., Berger, T., Riper, H., Luuk, L., Backlund, L., Carlbring, P., & Andersson, G. (in press). Working alliance as a predictor of change in depression during blended cognitive behaviour therapy. Cognitive Behaviour Therapy. doi: 10.1080/16506073.2018.1533577



Photo by: Janelle Chan, Brandon Lo, Jasmin Reyes


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