Abstract
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.
Highlights
Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy
Our findings can indicate whether the strength of the therapeutic alliance in text-based digital psychotherapy is comparable to the one found in face-to-face psychotherapy, and if there is a relation with treatment outcomes. This way, the current review aims to enhance responsible decision-making in terms of the therapeutic alliance in digital text-based psychotherapy
Other investigated groups were clients diagnosed with posttraumatic stress disorder (PTSD) or PTSDrelated symptoms (n = 6), obsessive-compulsive disorder (n = 2), binge-eating disorder (n = 1), preterm labor stress (n = 1), and chronic tinnitus (n = 1)
Summary
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. Internet-delivered psychotherapy can increase the availability of mental health care in underserved populations and during times of crisis (2), and could provide a responsible alternative or addition to fully face-to-face therapy. Notwithstanding the evidence for similar effectiveness, many consider the relationship between therapist and clients to be a central component of successful psychotherapy, and its role online is questioned and not fully understood among researchers, practitioners and clients (6)
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