The therapeutic alliance in blended versus face-to-face cognitive behavioral therapy for adolescents and young adults with a depressive disorder.

Introduction: A depressive disorder during adolescence is a serious and disabling disorder, which has a high impact on the development of adolescents. Blended treatment, combining online and face-to-face sessions, is effective and can reduce some of the barriers for adolescents to use mental health care. There is a lack of knowledge about whether therapeutic alliance is established in blended treatment for adolescents and young adults suffering from a depressive disorder. This study examines whether the quality of the therapeutic alliance differs when cognitive behavior therapy (CBT) is delivered in combination with online intervention (b-CBT) compared to solely face-to-face (FtF-CBT) and the extent to which a stronger therapeutic alliance is associated with better treatment outcome. Methods: A pragmatic quasi-experimental design was used. Data collected within two separate studies were combined. A total of 85 participants (80 % female), aged 13-22 (mean = 16.63, SD = 1.92) were recruited within mental health care institutions and diagnosed with a depressive disorder (using K-SADS). Assessments were done at pre-treatment (T0), after five weeks (T1), after ten weeks (T2), post-treatment (T3) and one to four weeks after treatment (T4) and included measures of depressive symptomatology (CDI-2). The therapeutic alliance was measured at T1, T2 and T3 by the TASC. t-tests for independent samples were used to test differences in therapeutic alliance rates between b-CBT and FtF-CBT at post-treatment. A linear growth model for depressive symptoms based on five time points with Latent Growth Curve Analysis (LGCA) was used to test whether the therapeutic alliance is associated with depressive symptoms. Results: No differences in therapeutic alliance between b-CBT and FtF-CBT were found on either client-rated or therapist-rated therapeutic alliance. For both intervention groups, no significant association between the therapeutic alliance and depressive outcome was found. Discussion: This study shows that providing part of CBT using an online environment does not have a negative impact on the therapeutic alliance. In contrast to earlier research, no association was found between the therapeutic alliance and therapy outcome in neither the b-CBT nor the FtF-CBT intervention.

Burnout, working alliance, and ward atmosphere: A multisite study of mental health professionals and patients with schizophrenia.

This study examined the association between burnout, psychological distress, ward atmosphere, and working alliance (WA) among mental health workers treating patients with schizophrenia spectrum disorder (SSD). Data were collected from 345 patients with SSD and 151 mental health workers across 98 residential facilities (RFs) as part of the DiAPAson project from October 2020 to October 2021. Participants were excluded from the study if they exhibited patient-operator matching errors, dropped out, or had many missing Maslach Burnout Inventory (MBI) scores. The final sample included 282 patients and 155 healthcare workers. Burnout was assessed using the MBI. Psychological distress was evaluated with the 12-item version of the General Health Questionnaire. WA and ward atmosphere were evaluated with the WA Inventory and the Ward Atmosphere Scale, respectively, in both staff and patients. Sociodemographic and clinical data was also collected and analysed. Burnout was associated with a less supportive ward atmosphere, a weaker WA, and higher staff distress. Severe psychiatric symptoms evaluated with Brief Psychiatric Rating Scale in patients were also linked to staff burnout levels. Discrepancies in the perceptions of the ward atmosphere and the WA were observed between staff and patients, with patients reporting better perceptions in both domains. Our findings highlight the complex dynamics of well-being within psychiatric care settings, emphasizing the importance of role clarity, professional autonomy, and a positive ward atmosphere in mitigating burnout. Interventions focused on such factors may help support mental health professionals involved in SSD patient care. ISRCTN registry ID ISRCTN21141466.

A Novel Approach to Examining Working Alliance Instability During Psychotherapy for Borderline Personality Disorder.

OBJECTIVE: This study aimed to quantify the instability of psychotherapy process variables by using a novel data-analytic approach. The study explored instability of the working alliance over 10 treatment sessions and its relationship with self-esteem. METHODS: Data were extracted from a randomized controlled trial, conducted in Switzerland, of a short-term intervention for borderline personality disorder. Sixty clients diagnosed as having borderline personality disorder were randomly assigned to receive either 10 sessions of good psychiatric management-brief version (GPM-BV) or GPM-BV combined with a relational principle called motive-oriented therapeutic relationship. Square successive differences were calculated for client and therapist ratings of alliance instability. Multilevel models were used to test within- and between-person associations of alliance instability with self-esteem. RESULTS: Although some preliminary analyses showed an association between a more stable alliance and higher self-esteem at the start of psychotherapy, the alliance did not become more stable over time. Alliance instability was not associated with self-esteem at either the within- or between-person level. CONCLUSIONS: This study highlights the advantages, procedures, and challenges of applying square successive differences to psychotherapy research data. The results suggest that the working alliance develops in complex ways and indicate the importance of continuing to use novel methods to capture dynamic psychotherapy processes.

Patients' Perceptions of Their Therapist: Effects of Race, Culture, and Cultural Competency on the Working Alliance.

OBJECTIVE: The purpose of this study was to investigate the extent to which patients feel racially and culturally similar to their therapist, patients' perceptions of their therapist's cultural competence, and how these factors relate to the working alliance in a naturalistic treatment setting. METHODS: Participants were 119 adult patients treated at a large outpatient clinic by clinicians with a range of professional backgrounds (e.g., psychiatric residents, psychologists in training, and staff therapists). Patients were asked to rate the level of racial and cultural similarity between themselves and their therapist and to provide their assessment of their therapist's cultural competency and of the working alliance. RESULTS: Findings suggest that patients' ratings of perceived cultural and racial similarity were not significantly related to the working alliance. However, perceptions of racial and cultural similarity were significantly associated with perceived therapist cultural competence. Perceived cultural competence was also strongly related to the working alliance. Finally, patients' ratings of their therapist's cultural competencies in the areas of awareness and skill, but not knowledge, predicted a strong working alliance after analyses controlled for ratings of racial and cultural similarity. CONCLUSIONS: This study suggests the importance of heightening mental health clinicians' awareness of the influence of culture on the therapeutic relationship and the important role of a therapist's cultural competencies (specifically, awareness and skill) in the working alliance, which may matter more to patients than perceptions of racial or cultural similarity.

Patients' perspective on the therapeutic relationship and session quality: the central role of alliance.

In this study, we examined how four components of the therapeutic relationship-working alliance, real relationship, and positive and negative affective reactions of the patient toward their therapist-relate to each other and to the psychotherapy session outcome, from the patient's point of view. Our simple comprised 700 adult patients in individual psychotherapy who were recruited and participated online. They underwent a baseline evaluation of their most recent therapy session, which encompassed a series of validated self-report measures focused on specific elements of the therapeutic relationship. The results revealed that, from the patient's perspective, working alliance, real relationship, and positive affective reactions toward the therapist were positively correlated with session outcome, while negative affective reactions were negatively correlated. All components predicted session outcome when simultaneously included in a regression model. Collectively, these four components accounted for 30% of the variance in session outcome. Factor analysis revealed four distinct factors, underlying perceptions of the therapeutic relationship. Notably, the bond dimension of the alliance was sufficiently different from the task and goal dimensions, warranting consideration as a distinct construct. These findings, although cross-sectional, lay the groundwork for a more nuanced investigation of multiple dimensions of the therapeutic relationship.

Examining within- and between-member cohesion and working alliance effects on group members' motivation: a preliminary actor-partner interdependence study.

OBJECTIVE: Informed by the person-environment fit theory, this preliminary study examined if a fit between a group member's treatment experience and their working therapy context (other group members' aggregated treatment experiences) were related to their level of motivation within a group treatment for healing from internalized weight stigma. METHOD: We examined the relationship between two types of within-member and between-member's group cohesion, working alliance, and motivation. Specifically, we utilized the Actor-Partner Interdependence Model to operationalize the impact of actor's within-member cohesion and alliance (personal changes over time) and between-member cohesion and alliance (individual differences) as well as partner's within-member cohesion and alliance (contextual changes over time) and between-member cohesion and alliance (contextual differences) on group members' motivation. This study utilized self-report data from 26 group members who participated in three online weight stigma psychotherapy groups. RESULTS: For cohesion, results suggested that the relationship between partner within-member cohesion and motivation was larger for members who reported low cohesion across all the sessions compared to the other members of their group. Additionally, an individual group member who perceived a group session more cohesive than they did on average, reported increased motivation in that session, and this relationship was stronger for members who on average perceived their group less cohesive than other group members. Lastly, session-level alliance was more strongly associated with an individual member's motivation in that session when the other group members reported higher group alliance on average. CONCLUSIONS: These findings underscore the significance of member-group fit in group therapy and the reciprocal impact of individual members and the group on each other's therapy outcomes.

Effect of Cultural Adaptation of a Smartphone-Based Self-Help Programme on Its Acceptability and Efficacy: Randomized Controlled Trial.

Background: Research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. However, direct comparisons of different levels of adaptations are scarce. Aims: This study used a smartphone-based self-help programme called Step-by-Step (Albanian: Hap-pas-Hapi) for the treatment of psychological distress among Albanian-speaking immigrants in Switzerland and Germany. Two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) were compared. We hypothesised that the deep structure adaptation would enhance the acceptance and efficacy of the intervention. Method: We conducted a two-arm, single-blind randomised controlled trial. Inclusion criteria were good command of the Albanian language, age above 18, and elevated psychological distress (Kessler Psychological Distress Scale score above 15). Primary outcome measures were the total score of the Hopkins Symptom Checklist and the number of participants who completed at least three (out of five) sessions. Secondary outcomes were global functioning, well-being, post-traumatic stress, and self-defined problems. Results: Two-hundred-twenty-two participants were included, of which 18 (8%) completed the post-assessments. The number of participants who completed the third session was equal in both conditions, with N = 5 (5%) and N = 6 (6%) respectively. Discussion: Drop-out rates were high in both conditions, and no group difference was found regarding the acceptance of the intervention. The high drop-out rate stands in contrast with other trials testing Step-by-Step. Future research should examine cultural factors impacting recruitment strategies, as insights could help to reduce participant drop-out rates in clinical trials.

An updated meta-analysis of the relation between adult attachment style and working alliance.

Objective: Previous meta-analyses have shown that client-rated working alliance is negatively correlated with attachment anxiety and attachment avoidance. The purpose of this study is to provide an updated meta-analysis of the relation between alliance and the two dimensions of attachment insecurity. Method: Random effects models were used to examine the relation between the working alliance and attachment anxiety and the relation between the working alliance and attachment avoidance. Results: The overall relation between alliance and attachment anxiety was r = -.09 (p = .01, k = 33, I2 = 43.7%). The overall relation between alliance and attachment avoidance was r = -.13 (p < .001, k = 33, I2 = 44.7%). There was no evidence that these relations varied across study characteristics such as client race or the number of therapists in the study. Conclusion: The results support the negative relations between client-rated alliance and both dimensions of client-rated attachment insecurity. Further research is needed to identify the factors that moderate this relationship, using a more diverse sample of study characteristics and a wider range of measures.

Humor in professional coaching: a literature review and research agenda.

Introduction: Extensive research has explored the incorporation of humor in therapy, revealing its potential positive effects on clients' mental well-being and personal growth. However, limited research exists on how coaching could benefit from humor as an intervention and how its utilization impacts the interaction processes and outcomes for both the coachee and coach. Therefore, our research focuses on the use and effects of spontaneous humor within professional dialogues. This paper aims to extract insights from academic literature on humor in adjacent fields and apply these insights to the context of coaching. Methods: This paper offers implications for coaching theory and practice, alongside a proposed research agenda. The initial phase involves analyzing reviews on humor in professional contexts, and coaching. Secondly, following the PRISMA guidelines for review, we identified 13 empirical studies, which address the role of humor in counseling, psychotherapy, and mentoring. Results and discussion: Our findings suggest that humor serves as a valuable tool for establishing and deepening the working alliance, fostering adaptive coping mechanisms in clients, and enhancing the cognitive and behavioral process. Moreover, humor is shown to be advantageous for professionals in navigating challenging client relationships. These findings hold significance for the realm of coaching practice as well. In light of these insights, we propose the integration of humor use in education toolkits for coaching professionals.

Therapeutic Alliance in Family-Based Treatment of Anorexia Nervosa: In-Person Versus Telehealth.

OBJECTIVE: The therapeutic alliance is broadly linked with positive outcomes. However, nearly all research in this area involves in-person therapy, whereas teletherapy has grown increasing common since the COVID-19 pandemic. There is now a pressing need to establish whether the nature and importance of the therapeutic alliance is impacted by teletherapy. This study examined therapeutic alliance in families of youth with anorexia nervosa who were participating in a randomized controlled trial that transitioned from in-person to telehealth visits during the COVID-19 pandemic. METHOD: We analysed data from 53 adolescents and their parents (20 began in-person, 33 began with telehealth). Both parents, youth and therapist completed the Working Alliance Inventory-Short Revised after 4 weeks of treatment. RESULTS: We found no significant differences across telehealth and in-person treatment for paternal or therapist reported data. However, both adolescents and mothers reported higher bond and goal-related alliance for in-person sessions compared to telehealth. CONCLUSIONS: Findings regarding alliance across telehealth and in-person sessions were mixed, with some preference among mothers and youth for in-person treatment. Future studies should determine whether possible adaptations can improve working alliance during family-based treatment for anorexia nervosa via telehealth.

Evidence for Bidirectional, Cross-Lagged Associations Between Alliance and Psychological Distress in an Unguided Mobile-Health Intervention.

Bidirectional associations between changes in symptoms and alliance are established for in-person psychotherapy. Alliance may play an important role in promoting engagement and effectiveness within unguided mobile health (mHealth) interventions. Using models disaggregating alliance and psychological distress into within- and between-person components (random intercept cross-lagged panel model), we report bidirectional associations between alliance and distress over the course of a 4-week smartphone-based meditation intervention (n=302, 80.0% elevated depression/anxiety). Associations were stable across time with effect sizes similar to those observed for psychotherapy (ßs=-.13 to -.14 and -.09 to -.10, for distress to alliance and alliance to distress, respectively). Alliance may be worth measuring to improve the acceptability and effectiveness of mHealth tools. Further empirical and theoretical work characterizing the role and meaning of alliance in unguided mHealth is warranted.

The working alliance inventory - short version: psychometric properties of the patient and therapist form in youth mental health and addiction care.

The therapeutic alliance is considered to play an important role in youth treatment. The commonly used versions of the Working Alliance Inventory (WAI) are based on Bordin's three-dimensional alliance model. However, previous psychometric studies of the WAI did not find this three-dimensional structure in youth psychotherapy. These earlier findings may indicate different perceptions of the alliance by adolescent versus adult patients, but may also be due to methodological shortcomings. The current study aims to address previous study limitations by evaluating the factor structure of the short version of the WAI (WAI-S) in youth treatment in multilevel analysis to address the hierarchical structure of the alliance data. We examined the psychometric properties of the patient (n = 203) and therapist (n = 62) versions of the WAI-S in youth mental health and addiction care and tested four multilevel models of alliance at start of treatment and 2-month follow-up. Our results suggests a two-factor model for youth and a three-dimensional model for their therapist at both time points. Since this is the first study that finds a best fit for a two-dimensional construct of alliance in youth, more research is needed to clarify whether the differences in alliance dimensions are due to measurement differences between the WAI-S for youth and therapists or whether youth and their therapists truly differ in their perceptions of the concept of alliance.

The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss.

BACKGROUND: Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss. METHODS: 228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10). RESULTS: Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms. CONCLUSION: The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions. TRIAL REGISTRATION: Not applicable.

Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial.

BACKGROUND: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. OBJECTIVE: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. METHODS: We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. RESULTS: Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005). CONCLUSIONS: To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance. TRIAL REGISTRATION: ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-016-1511-1.

Patient Engagement with Conversational Agents in Health Applications 2016-2022: A Systematic Review and Meta-Analysis.

Clinicians and patients seeking electronic health applications face challenges in selecting effective solutions due to a high market failure rate. Conversational agent applications ("chatbots") show promise in increasing healthcare user engagement by creating bonds between the applications and users. It is unclear if chatbots improve patient adherence or if past trends to include chatbots in electronic health applications were due to technology hype dynamics and competitive pressure to innovate. We conducted a systematic literature review using Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology on health chatbot randomized control trials. The goal of this review was to identify if user engagement indicators are published in eHealth chatbot studies. A meta-analysis examined patient clinical trial retention of chatbot apps. The results showed no chatbot arm patient retention effect. The small number of studies suggests a need for ongoing eHealth chatbot research, especially given the claims regarding their effectiveness made outside the scientific literatures.

The development of working alliance in early stages of care from the perspective of patients attending a chiropractic teaching clinic.

BACKGROUND: The clinician-patient relationship has consistently been found to predict treatment success in both physical and mental health settings. This relationship has been operationalised in the literature as "Working Alliance," which consists of three key components: patient-clinician agreement on the goals of care, agreement on the tasks required to achieve those goals, and the establishment of a strong bond. While research has demonstrated the impact of working alliance in physical health settings, it often measures working alliance early in patients' care journeys. However, no primary research has investigated how early working alliance develops between patients and chiropractors. Evidence suggests that musculoskeletal practitioners may require further training to feel confident in establishing working alliance. Therefore, this study aims to explore the development of working alliance in the early stages of chiropractic care from the patients' perspective to inform evidence-based practice. METHODS: Participants for this qualitative study were recruited from a teaching clinic at a specialised healthcare professions training university in the United Kingdom between September 2022 and April 2023. A total of 25 adult patients completed semi-structured interviews during the early stages of their care. The interview transcripts were analysed using Reflexive Thematic Analysis, from a critical realist stance. RESULTS: The findings highlight that an early working alliance entails the gradual development of patients' confidence in their decision to seek help from trainee chiropractors to alleviate their symptoms. The four themes describe the impact of the clinical context on patients' expectations, the trainee chiropractors' qualities that participants considered important for early working alliance, the role of explanations, and the interplay between pain and early working alliance. CONCLUSIONS: Establishing an early trainee chiropractor-patient working alliance involves a process of building patients' confidence in the trainee chiropractors' expertise, identifying the correct goals of care, and recognising the value of the proposed treatment plan. Factors shaping this process include the context of the care journey, patients' perceptions of trainee chiropractors' qualities, their bodily sensations, their expectations, their past experiences, and their satisfaction with trainee chiropractors' explanations.

Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study.

BACKGROUND: Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored. OBJECTIVE: This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention. METHODS: Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention. RESULTS: Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would. CONCLUSIONS: Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

The relationship between expressive suppression, therapeutic bond, and treatment outcomes of a positive affect intervention for adults with anxiety and/or depression.

Expressive suppression (ES; reducing emotional expression) is linked with reduced social connectedness in individuals with anxiety or depression. One implication is that people who use ES may have difficulty establishing a bond with their therapist which may impede clinical improvement. We examined this hypothesis in 33 adults with clinically elevated anxiety or depression receiving treatment focused on enhancing positive thoughts, emotions, and behaviors. At baseline, participants rated ES for positive and negative emotions during a standardized conversation task designed to generate connectedness. They also rated measures of early (session 3) perceived therapeutic bond and treatment outcomes (i.e. positive affect and social connectedness). ES of positive (r = -.39, p = .018), but not negative (r = .06, p = .747), emotions was negatively associated with therapeutic bond. Therapeutic bond mediated the relationship between greater ES of positive emotions during affiliation and lower post-treatment positive affect, 95% bias-corrected bootstrap confidence interval [-0.021, -0.000], adjusted for pre-treatment positive affect, as well as lower post-treatment social connectedness [-0.397, -0.015]; however, the indirect effect was not significant when accounting for pre-treatment social connectedness (p > .05). ES of positive emotions may be an important factor in the development of therapeutic bond and therefore treatment outcomes for individuals with anxiety or depression.

The effect of the cultural formulation interview on therapeutic working alliance: a study protocol.

Background: The Cultural Formulation Interview (CFI) is designed to improve understanding of patients' mental health care needs. The lack of empirical evidence on the impact and effectiveness of CFI use in clarifying people's perspectives, experiences, context, and identity, and in preventing cultural misunderstandings between migrant patients and clinicians, inspired this study. The objective is to examine the effect of the CFI on the strength of therapeutic working alliances, and the potential mediating or moderating role of perceived empathy. Materials and methods: A multicenter randomized controlled trial will be conducted, involving migrant patients, their confidants, and clinicians. The CFI will be administered in the intervention group, but not in the control group. Validated questionnaires will be used to assess therapeutic working alliances and perceived empathy. T-tests and linear regression analyses will be conducted to investigate between-group differences and possible mediating or moderating effects. Results: This study will indicate whether or not the CFI strengthens the therapeutic working alliance between patients and clinicians, as moderated and/or mediated by perceived empathy. Discussion: Research on the effect and impact of using the CFI in mental health care for migrant patients is important to clarify whether its use strengthens the therapeutic working alliance with clinicians. This can lead to a reduction in cultural misunderstandings and improve mental health care for migrant patients. The results may also be important for the implementation of the CFI as a standard of care. Ethics and dissemination: This research protocol was tailored to the needs of patients in collaboration with experts by experience. It was approved by the Ethical Review Board of the Tilburg Law School and registered in the Clinical Trials Register under number NCT05788315. Positive results may stimulate further implementation of the CFI in clinical practice, and contribute to improving the impact of the CFI on the therapeutic working alliances.

Use Intention and User Expectations of Human-Supported and Self-Help eHealth Interventions: Internet-Based Randomized Controlled Trial.

BACKGROUND: Self-help eHealth interventions provide automated support to change health behaviors without any further human assistance. The main advantage of self-help eHealth interventions is that they have the potential to lower the workload of health care professionals. However, one disadvantage is that they generally have a lower uptake. Possibly, the absence of a relationship with a health care professional (referred to as the working alliance) could lead to negative expectations that hinder the uptake of self-help interventions. The Unified Theory of Acceptance and Use of Technology (UTAUT) identifies which expectations predict use intention. As there has been no previous research exploring how expectations affect the adoption of both self-help and human-supported eHealth interventions, this study is the first to investigate the impact of expectations on the uptake of both kinds of eHealth interventions. OBJECTIVE: This study investigated the intention to use a self-help eHealth intervention compared to a human-supported eHealth intervention and the expectations that moderate this relationship. METHODS: A total of 146 participants were randomly assigned to 1 of 2 conditions (human-supported or self-help eHealth interventions). Participants evaluated screenshots of a human-supported or self-help app-based stress intervention. We measured intention to use the intervention-expected working alliance and the UTAUT constructs: performance expectancy, effort expectancy, and social influence. RESULTS: Use intention did not differ significantly between the 2 conditions (t142=-1.133; P=.26). Performance expectancy (F1,140=69.269; P<.001), effort expectancy (F1,140=3.961; P=.049), social influence (F1,140=90.025; P<.001), and expected working alliance (F1,140=26.435; P<.001) were positively related to use intention regardless of condition. The interaction analysis showed that performance expectancy (F1,140=4.363; P=.04) and effort expectancy (F1,140=4.102; P=.045) more strongly influenced use intention in the self-help condition compared to the human-supported condition. CONCLUSIONS: As we found no difference in use intention, our results suggest that we could expect an equal uptake of self-help eHealth interventions and human-supported ones. However, attention should be paid to people who have doubts about the intervention's helpfulness or ease of use. For those people, providing additional human support would be beneficial to ensure uptake. Screening user expectations could help health care professionals optimize self-help eHealth intervention uptake in practice. TRIAL REGISTRATION: OSF Registries osf.io/n47cz; https://osf.io/n47cz.